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CASE REPORT
Ahead of print publication  

Intraocular foreign body presenting as recalcitrant hypopyon anterior uveitis


1 Department of Cornea, Sankara Eye Hospital, Bengaluru, Karnataka, India
2 Department of Medical Retina and Uvea, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission06-Nov-2020
Date of Acceptance05-Jan-2021
Date of Web Publication17-Apr-2021

Correspondence Address:
Sailatha Ganesh,
Department of Medical Retina and Uvea, Sankara Eye Hospital, Varthur Road, Kundanahalli Gate, Bengaluru - 560 037, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjo.tjo_1_21

  Abstract 

A 38-year-old male with a history of trauma presented to us with pain and decreased vision in the left eye (LE). Previously, the patient had been diagnosed with hypopyon uveitis and was prescribed topical steroids. We performed slit-lamp examination of the LE and found exudates in the anterior chamber (AC) extending from 6 to 9 o'clock, along with circumciliary congestion and pigmented keratic precipitates. We made a diagnosis of infectious anterior hypopyon uveitis; however, all of its causes were ruled out upon the necessary investigations, which returned normal results. The patient was started on topical and oral antibiotics, and subsequently, there was complete hypopyon resolution. Five months later, he presented with similar complaints. An examination revealed a black elevated lesion in the AC at 8 o'clock suspicious of an intraocular foreign body (IOFB), along with 1 mm hypopyon. An X-ray orbit examination confirmed the IOFB presence, and the IOFB was surgically removed from the AC. Three weeks after this surgery, the patient presented with a recurrence of similar symptoms. The nasal pterygium adjacent to the location of the previously removed IOFB was inflamed with an underlying black elevated limbal nodule, which was determined to likely be a remnant of the IOFB in the subconjunctival space. Here, we report a case of penetrating IOFB that was initially detected in the AC. Its remnant extraocular component persisted in the subconjunctival space, and its incomplete removal led to recurrent inflammation.

Keywords: Hypopyon, intraocular foreign body, subconjunctival space



How to cite this URL:
Balasubramaniam A, Ganesh S, Minija CK, Dubey N. Intraocular foreign body presenting as recalcitrant hypopyon anterior uveitis. Taiwan J Ophthalmol [Epub ahead of print] [cited 2021 Dec 8]. Available from: https://www.e-tjo.org/preprintarticle.asp?id=313919




  Introduction Top


Intraocular foreign bodies (IOFBs) in the anterior and posterior segments can cause a range of complications in the eye if left in place.[1] Metallic foreign bodies in the eye can be lodged in the angle presenting as recurrent hypopyon uveitis with an extraocular component in the adjacent subconjunctival space masked by a pseudopterygium. Hence, a detailed history of trauma must be elicited, and a thorough slit-lamp examination and gonioscopy should be performed to look for a possible entry site that may conceal part of the foreign body. X-ray orbit examination will also guide the treatment plan.[2] Here, we report a case of penetrating IOFB presenting as recalcitrant hypopyon anterior uveitis.


  Case Report Top


A 38-year-old male came to our hospital owing to decreased vision and episodes of redness and pain in the left eye (LE) for the previous 5 months. The patient had a history of injury with a metallic foreign body in his LE 5 months earlier while working. He was on topical antibiotics and antifungals when he presented to our hospital. His best-corrected visual acuity (BCVA) was 6/9, N6 and 6/12, N8 in the right eye and LE, respectively. The right eye was normal on examination. However, the LE had nasal pterygium, circumciliary congestion, and exudates extending from 6 to 9 o'clock in the anterior chamber (AC) [Figure 1]a, with dense AC reaction and some pigmented keratic precipitates on the endothelium. Fundus examination was normal in both eyes.
Figure 1: (a) slit-lamp photo of left eye showing circumciliary congestion, and exudates in the anterior chamber from 6 to 9 o'clock. (b) Brown-colored iris granulomas. (c) Black lesion at 8 o'clock suspicious of intraocular foreign body. (d) Fleshy pterygium, with adjacent dellen and hypopyon

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A presumptive diagnosis of acute anterior hypopyon uveitis was made, and the patient was started on topical steroids and antibiotics along with systemic antibiotics. Subsequent follow-up visits showed a reduction in AC reaction and complete resolution of hypopyon. All relevant investigations were within normal limits, and the patient was lost to follow-up.

Five months later, he presented with similar complaints in his LE. An examination revealed 1 mm hypopyon, multiple pigmented iris granulomas [Figure 1]b, a black elevated lesion on the iris at 8 o'clock that was suspicious for IOFB and was associated with an overlying dellen on the cornea [Figure 1]c, and an adjacent fleshy pterygium [Figure 1]d. Gonioscopy and ultrasound biomicroscopy revealed no evidence of a foreign body in the angle.

Foreign body-induced granulomatous uveitis was suspected. X-ray orbit [Figure 2]a in the anteroposterior (AP) view showed a 3–4 mm foreign body.
Figure 2: (a) Anteroposterior view of the X-ray orbit showing a foreign body of 3–4 mm (b) Three weeks post intraocular foreign body removal; an adjacent subconjunctival nodule with black discoloration underneath at 9 o'clock was found. (c) Persistent hypopyon. (d) Anteroposterior and lateral view of X-ray orbit showing a 3 mm × 2 mm foreign body

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We decided to surgically remove the foreign body. Intraoperatively, the IOFB was seen on the surface of the iris at 8 o'clock in the LE. It was removed under local anesthesia through a limbal incision using intraocular forceps. On its removal, it disintegrated into a powdery substance. As there was no other residual element noted, a thorough AC wash was done, followed by injection of 0.1 ml of 0.5% intracameral Vigamox. After 10 days, the BCVA was 6/18, N12, and there was persistence of inflammation.

Assuming the foreign body was completely removed, and considering its chronic intraocular location for 5 months, we suspected fungal infection as the cause for the persistent inflammation at 10 days post surgery. Thus, the patient was started on oral ketoconazole 400 mg twice daily for 2 weeks.

At the 3-week postoperative review, the patient presented with decreased vision in the LE (3/60), and there was a dark pigmented subconjunctival nodule/granuloma at 9 o'clock [Figure 2]b underlying the pterygium, as well as persisting hypopyon [Figure 2]c. Suspecting a remnant of the IOFB in the subconjunctival space that probably extended into the AC from the entry site, we repeated the X-ray orbit of both the AP and lateral view [Figure 2]d. The results showed a 3 mm × 2 mm foreign body, confirming our diagnosis. The patient, therefore, underwent wound exploration. Intraoperatively, the pseudopterygium was dissected, local peritomy was done, and bare sclera was exposed. The sclera was thin and necrotic, and an underlying 3 mm iron foreign body [Figure 3]a was located at the sclerolimbal junction. Its entry site was identified to be from the nasal limbus through the angle into the AC. The foreign body was extracted, and the necrotic tissue around it was removed. There was no uveal tissue prolapse or any corneal entry noted at the wound site. This was an extraocular procedure only; the AC was not entered. No scleral patch graft was placed. The local wound area was irrigated with an antibiotic, and the conjunctiva was closed with 8-0 vicryl sutures.
Figure 3: (a) foreign body. (b) Two weeks post subconjunctival foreign body removal, showing a fibrous ingrowth from 7 to 9 o'clock

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At the 5-day postoperative review, his BCVA was 6/36, N18. The patient's final visit with us 2 weeks later showed a BCVA of 6/12, N10, and a fibrous ingrowth was seen from 7 to 9 o'clock [Figure 3]b. There was complete resolution of hypopyon and the conjunctival nodule.


  Discussion Top


IOFBs can present with various symptoms and signs depending on the location in the eye, duration from the initial trauma, size, and material composition.[3] IOFBs account for 18%–41% of open-globe injuries. These foreign bodies are usually seen in the posterior segment in the majority (58%–88%) of the cases, while most others are in the AC (10%–15%).[1]

IOFBs can cause mechanical injury and also chemical injury if they contain iron (siderosis) or copper (chalcosis), but the most important risk of a retained foreign body is persistent inflammation and infection, which are difficult to differentiate.[4]

Exogenous fungal infections typically have a latency period lasting weeks to months; this is unlike bacterial infections, which usually present within days. In a case report by Hwang et al.,[5] a fungal mass appeared in the AC 10 weeks after the occurrence of trauma; moreover, the formation of whitish exudates in the AC suggested a probable fungal etiology. Our case was similar in that time since injury from a metallic IOFB was 5 months and the presence of exudates in the AC aroused the suspicion of a fungal etiology. Thus, we started the patient on oral antifungals.

AC foreign bodies can be missed for several reasons. They might be camouflaged by excessive iris pigment release due to the persistence of the IOFB; they may be lying within the angle not visible on slit-lamp examination; or they might be covered by inflammatory exudates, as in our case. A very careful examination of the adjacent iris and angle structures should be done to look for any intraocular component of an extraocular FB and its entry site. There are reports of anterior segment IOFB causing chronic hypopyon uveitis.[6]

Because there is a space between the apex of the pterygium on the cornea and its base on the sclera, the foreign body can become lodged there. Thus, for patients who show persistent localized subconjunctival elevation and congestion causing a pseudopterygium appearance, as in our case, a careful search should be made for a subconjunctival foreign body.[7]

The IOFB extending into the AC was only a tiny fragment, with its main component located in the extraocular subconjunctival space. Moreover, intraoperatively, the IOFB was noted to be <1 mm in size, and it disintegrated into a powdery substance during its removal with intraocular forceps. Considering the above two factors, the repeat X-ray orbit examination revealed a foreign body 3 mm × 2 mm in size, despite the initial removal of a fragment from the AC.

In cases of penetrating IOFB trauma, a thorough examination is mandatory, as multiple sites of foreign body impaction are possible. Failure to recognize this can lead to remnants causing persistent inflammation and incomplete response to treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient gave his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due effort will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.

 
  References Top

1.
Loporchio D, Mukkamala L, Gorukanti K, Zarbin M, Langer P, Bhagat N. Intraocular foreign bodies: A review. Surv Ophthalmol 2016;61:582-96.  Back to cited text no. 1
    
2.
Huang YM, Yan H, Cai JH, Li HB. Removal of intraocular foreign body in anterior chamber angle with prism contact lens and 23-gauge foreign body forceps. Int J Ophthalmol 2017;10:749-53.  Back to cited text no. 2
    
3.
Mahmoud A, Messaoud R, Abid F, Ksiaa I, Bouzayene M, Khairallah M. Anterior segment optical coherence tomography and retained vegetal intraocular foreign body masquerading as chronic anterior uveitis. J Ophthalmic Inflamm Infect 2017;7:13.  Back to cited text no. 3
    
4.
Chaudhry IA, Shamsi FA, Al-Harthi E, Al-Theeb A, Elzaridi E, Riley FC. Incidence and visual outcome of endophthalmitis associated with intraocular foreign bodies. Graefes Arch Clin Exp Ophthalmol 2008;246:181-6.  Back to cited text no. 4
    
5.
Hwang HJ, Lee YW, Koh KM, Hwang KY, Kwon YA, Song SW, et al. Lenticular fungal infection caused by Aspergillus in a patient with traumatic corneal laceration: A case report. BMC Ophthalmol 2020;20:173.  Back to cited text no. 5
    
6.
Mete G, Turgut Y, Osman A, Gülşen U, Hakan A. Anterior segment intraocular metallic foreign body causing chronic hypopyon uveitis. J Ophthalmic Inflamm Infect 2011;1:85-7.  Back to cited text no. 6
    
7.
Park YM, Jeon HS, Yu HS, Lee JS. A subconjunctival foreign body confused with uveal prolapse. Indian J Ophthalmol 2014;62:730-1.  Back to cited text no. 7
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