intraocular foreign bodies risk factors of visual loss: risk factors of visual loss: 1) m echanism...
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INTRAOCULAR FOREIGN BODIES
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Risk factors of visual loss:
1)Mechanism of injury
2)Size of the IOFB
3) Location of the IOFB
4)Endophthalmitis
5) PVR
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25% of patients who sustained IOFB injury had final visual acuities of less than 20/200
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PREOPERATIVE PREPARATION
History Ophthalmic examination Appropriate neuroimaging Consideration of antimicrobials
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HISTORY:
Accurate history-taking with attention to the mechanism of injury (e.g. knife wound, explosive device, shotgun blast)
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OPHTHALMIC EXAMINATION:
Visual Acuity Endophthalmitis
Globe rupture Retinal detachment An afferent pupillary defect
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NEUROIMAGING:
CT SCAN B-scan ultrasonography Ultrasound biomicroscopy (UBM) X Ray MRI
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PREOPERATIVE SYSTEMIC ANTIBIOTICS:
Gram-positive organisms
- coagulase-negative staphylococci
- streptococci Gram-negative Fungal organisms
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Third-generation fluoroquinolone:
- levofloxacin Fourth-generation fluoroquinolone:
- moxifloxacin
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OPERATIVE CONSIDERATIONS
Timing of surgery (delayed versus immediate)
The route and instruments used for IOFB extraction
The role of intraoperative antibiotics
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Delayed versus immediate intraocular foreign body removal
The presence or absence of clinical endophthalmitis
The stability of the patient for an extended surgical procedure
The availability of well trained operating room personnel
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Advantages to immediate IOFB removal:
1) A decrease in the risk of endophthalmitis
2) A decrease in the rate of PVR
3) A single procedure under anesthesia with its attendant risks
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Advantages to delayed IOFB removal:
1) Better integrity of the repaired laceration
2)Less severe anterior segment pathology (e.G. Resolution of corneal edema, hyphema resorption)
3)The presence of a PVD
4)Resorption of some V.H
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ROUTE OF IOFB EXTRACTION
Strategies for IOFB extraction at this point depend on the nature of the material and its size
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intraocular magnet:
Small (<1.0 mm) metallic ferromagnetic IOFBs
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basket forceps:
Medium-sized IOFBs (1.0–3.0 mm) Metallic Stone concrete
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diamond-coated forceps:
Larger IOFBs (3.0–5.0 mm) Glass fragments
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POSTOPERATIVE CARE:
endophthalmitis (5-7%) RD (6.3 to 36.8%) PVR ( 6.7 to 46% )
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Inert foreign body:
- Stone
- Glass
- Porcelain
- Plastic
- cilia
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Reactive foreign body:
- Zinc
- Aluminum
- Copper
- iron
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Zinc and aluminum:
- Minimal inflammation
- Encapsulated
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SIDEROSIS
Risk factors:
- Content
- Location
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RPE cells Pars plana TM Corneal epithelium Lens epithelium Pupillary constrictor muscle
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CLINICAL SIGNS:
Nyctalopia ↓ VL Mydriasis Iris heterochromia Brown deposit beneath the ant. Lens
capsule cataract
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Peripheral retinal pigmentation diffuse retinal pigmentation Optic disc atrophy POAG
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Abnormal ERG
Increased a-Wave and normal b-Wave
Diminishing b-Wave
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CHALCOSIS
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IOFBs containing over 95% copper :
severe , rapidly progressive purulent endoph-thamitis
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IOFBs containing between 85 and 95% copper:
visual loss→ deposition of copper in
1) descment΄s membrane
2) ant. Lens capsule
3) vit. Cavity
4)ILM
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K-F ring Ant. Subcapsular sunflower cataract Greenish discoloration of the vitreous Greenish refractile deposits in the ILM
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IOFBs containing less than 85 % copper
usually produce no detectable change
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CONCLUSIONS:
IOFBs are common in open globe injuries
Clinicians must remain suspicious of a possible IOFB in any traumatized eye
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