AN Stangos

AR Rosenthal

B Billi

F Kuhn

H Neubauer

JS Duker

MJ Weiss

MR Dayan

NA Rao

R Neumann

RB Welch

S Kaushik

VA Deramo

Journal of Ophthalmic Inflammation and Infection

English

PubMed

Steven Yeh

Martina Ralle

Isabella T. Phan

Peter J. Francis

James T. Rosenbaum

Christina Joy Flaxel

Springer - Publisher Connector

BRIEF REPORT
Occult intraocular foreign body masquerading as panuveitis:
inductively coupled mass spectrometry
and electrophysiologic analysis
Steven Yeh & Martina Ralle & Isabella T. Phan &
Peter J. Francis & James T. Rosenbaum &
Christina Joy Flaxel
Received: 1 July 2011 /Accepted: 19 July 2011 /Published online: 31 July 2011
# The Author(s) 2011. This article is published with open access at Springerlink.com
Introduction
Retained intraocular foreign bodies (IOFB) may rarely
present as chronic uveitis, either with isolated anterior
uveitis or with posterior segment inflammation. The heavy
metals copper and iron may lead to both acute and chronic
inflammatory processes resulting in severe inflammation,
retinal degeneration, and resultant visual loss. Penetrating
or perforating ocular injuries are easily recognizable in the
majority of cases; however, a high index of suspicion is
necessary to recognize an occult penetrating injury because
of the severe visual impairment that can ensue. We describe
an unusual case of a retained IOFB, which presented
6 months after a probable occult penetrating injury from
metallic IOFB trauma. The severity of the patient's
inflammation on presentation and retinal findings in the
contralateral eye prompted further diagnostic testing in-
cluding inductively coupled mass spectrometry of the IOFB
and electrophysiologic testing. This rare clinical scenario,
laboratory findings, and therapeutic considerations are
presented.
Case report
A 19-year-old Caucasian male was referred to the Casey
Eye Institute with a 3-week history of decreased vision
and photophobia involving the right eye (OD). He
reported hammering metal on metal 6 months prior
and felt a foreign object enter his eye. The patient was
evaluated at an urgent care facility where his eye was
flushed, and tobramycin–dexamethasone ointment was
prescribed. The patient's foreign body sensation im-
proved, and he remained asymptomatic until 3 weeks
prior to our evaluation. After ophthalmologic evaluation
by another physician, he was referred to our service for
suspicion of an occult IOFB.
Visual acuities were 20/50 OD and 20/20 in the left eye
(OS). Slit lamp examination showed trace anterior chamber
cell and 2+ vitreous cell OD and trace anterior chamber cell
OS. Dilated funduscopic examination (DFE) OD showed
mild optic disc edema, retinal vascular tortuosity, and a
white elevated mass inferotemporally with surrounding
pigmentary mottling and an overlying vitreous condensa-
tion (Fig. 1). DFE OS showed a nerve fiber layer
hemorrhage along the superotemporal arcade. A B-scan
ultrasound confirmed a metallic IOFB and orbital CT scan
revealed metallic artifact from the IOFB with a possible
posterior rupture (Fig. 2). No other foreign bodies were
identified.
S. Yeh
Emory Eye Center, Emory University School of Medicine,
Atlanta, GA, USA
M. Ralle
Department of Biochemistry and Molecular Biology,
Oregon Health and Science University,
Portland, OR, USA
I. T. Phan
Department of Ophthalmology, University of California San
Francisco School of Medicine,
San Francisco, CA, USA
P. J. Francis : J. T. Rosenbaum :C. J. Flaxel (*)
Casey Eye Institute, Oregon Health and Science University,
3375 SW Terwilliger Blvd.,
Portland 97239-4197 OR, USA
e-mail: flaxelc@ohsu.edu
J Ophthal Inflamm Infect (2012) 2:99–103
DOI 10.1007/s12348-011-0035-9
Surgical technique
Pars plana vitrectomy (PPV) and IOFB extraction were
planned for the presumptively encapsulated IOFB. A
standard three-port 20-gauge PPV was performed, taking
care to dissect all of the vitreoretinal adhesions extending
from the apex of the capsule surrounding the IOFB.
Following vitreous dissection around the IOFB, alligator
forceps were used to free the IOFB and its fibrotic capsule
from the retina. Because of the dense adhesions completely
surrounding the IOFB, additional dissection with the
vitreous cutter was necessary to free the fibrotic adhesions
extending from the IOFB capsule to the retina. After
successfully liberating the IOFB from the retina, the
superotemporal sclerotomy was enlarged with a micro-
vitreoretinal blade and the IOFB was removed from the eye
with alligator forceps. Next, 7-0 vicryl suture was used to
close the temporal aspect of the superotemporal sclerotomy
site to address the large retinal defect and associated
inferotemporal retinal detachment, which were observed.
The retinal defect was marked with endodiathermy; air–
fluid exchange was performed, and the break was
surrounded with endolaser. A 276-tire supporting the
inferior 180-degree scleral bed, 240-band, and 70-Watzke
sleeve secured with 5-0 Mersilene horizontal mattress
sutures were used to provide additional support to the
inferior retinal defect. Twenty percent SF6 gas was
exchanged for air, and the sclerotomy and conjunctiva were
closed in standard fashion.
Metallurgic analysis
Sample preparation
Of the ferromagnetic IOFB, 4.0 mg was added to 1.5 ml of
aqua regia (3:1 parts HNO3:HCl, Fisher, Metals Grade) and
heated under reflux for 3 h during which the metal fragment
completely dissolved. The resulting bright-yellow solution
was brought up to exactly 10 ml with 1% HNO3. The
solution was diluted into 1% HNO3 to fall within the range
of the standard curve (the sample was measured a total of
four times at dilutions of 100×, 1,000×, 100×, and 2,000×).
Inductively coupled plasma mass spectrometry analysis
Inductively coupled plasma mass spectrometry (ICP-MS)
analysis was performed using an Agilent 7700× system
equipped with an ASX-250 Autosampler. The system was
operated at a radio frequency power of 1,550 W, an argon
Fig. 1 Fundus photograph of the right eye at the patient's initial
presentation showed mild vitreous haze, optic disc edema, and retinal
vascular tortuosity (a) with an inferotemporally located yellow–white,
well-circumscribed mass with surrounding chorioretinal hyperpigmen-
tation and atrophy (b). c Fundus photograph of the left eye shows
focal intraretinal hemorrhage within the superotemporal arcade. d, e A
fluorescein angiography showed leakage from the optic nerve,
peripapillary retinal vessels, and mild leakage in the parafoveal
region. f Fluorescein angiography of the left eye showed no optic
disc or vascular leakage
100 J Ophthal Inflamm Infect (2012) 2:99–103
flow rate of 15 L/min, carrier gas flow rate of 1.04 L/min,
and helium (He) gas flow rate of 4.3 ml/min (only in He
mode). To evaluate which elements were present in the
dissolved fragment, count rates for most common elements
(∼50) were monitored using a constant spray of the sample.
During this qualitative portion of the analysis, only iron
showed an extremely high count rate, while few elements
gave slightly elevated count rates that were ∼103× less than
those for iron.
For the subsequent quantitative analysis, a method was
set up for all elements that had shown elevated count rates.
Data were quantified using a seven-point (0, 1, 10, 100,
1,000, 2,000, and 5,000 ppb (ng/g)) calibration curve with
external standards for Mg, Al, Ca, Fe, Cu, Zn, and Pb. All
data were acquired in He mode to remove interference from
oxides, argides, and chlorides. For each sample, run data
were acquired in triplicate and averaged. Internal standards
introduced with the sample were used to correct for plasma
instabilities. The National Institute of Standards and
Technology standard reference material was used to ensure
elemental recovery of >90%.
ICP-MS results
The quantitative metallic composition derived from ICP-
MS analysis is summarized in Table 1. Approximately,
Table 1 Composition of metallic IOFB using inductively coupled
mass spectrometry
Element Average (ppm) Standard deviation Total (%)
Fe 389.32 12.29 97.33
Cu 0.11 0.04 0.03
Zn 0.77 0.80 0.19
Al 1.01 NA 0.25
Ca 3.37 NA 0.84
Pb 0.01 0.01 0.00
Fig. 2 B-scan ultrasound of the right eye shows an intraocular foreign
body (IOFB) with shadowing behind the IOFB on the 7:30 equator
posterior (730EP) and 7:30 longitudinal (L730) scans (a, b). There is
moderate vitreous debris overlying the IOFB but no distinct track in
the vitreous (white arrow). c Axial CT scan confirms IOFB with
metallic streaking artifact. d Gross photograph of metallic IOFB prior
to inductively coupled mass spectrometry
J Ophthal Inflamm Infect (2012) 2:99–103 101
97.3% of the metallic IOFB was identified as iron,
measuring 389±12.3 ppm (±standard deviation). Other
elements identified included copper (0.11±0.04) and zinc
(0.77±0.80). Calcium and aluminum were also found in
minimal quantities. Mercury, cadmium, and lead were not
identified in any significant quantity.
Electrophysiologic testing
A full-field electroretinogram (ERG) was performed
2 months following surgery, as the patient's vision remained
20/50 despite successful anatomic reattachment and a
normal foveal contour. Photoreceptor responses were
severely abnormal for the right eye. Rods and dark-
adapted cone responses were severely subnormal. The
scotopic bright flash a-wave responses were moderately
subnormal, whereas the b-wave amplitudes were markedly
subnormal, creating an electronegative configuration con-
sistent with siderosis.
Clinical course
At the final 9-month follow-up, the patient's visual acuity
improved to 20/30 OD and remained 20/20 OS. Slit lamp
examination showed no evidence of anterior chamber or
vitreous inflammation. The retina remained attached with
good chorioretinal scarring at the IOFB impact site, which
was supported by the scleral buckle. The retinal hemor-
rhage OS resolved, and no inflammation was observed. The
ERG was repeated and the right eye again demonstrated
decreased amplitudes and prolonged timing of both rod-
and cone-driven responses, though these were improved
compared to the initial ERG.
Discussion
Occult penetrating globe injuries with retained IOFBs are a
relatively infrequent occurrence [1–6] and may rarely
present with chronic anterior or posterior segment inflam-
mation [2, 5, 6]. Besides meticulous ophthalmic examina-
tion, B-scan ultrasound, ultrasound biomicroscopy, and CT
scans are extremely useful in the diagnosis of occult IOFB
injuries. ERG changes have been characterized in the
context of siderosis associated with IOFB injuries [1, 3].
In addition, retained copper IOFBs may result in acute [1]
or chronic chalcosis [7–9]. In both siderosis and chalcosis,
ERG changes may be partially reversible in some patients
[10, 11].
Following PPV/IOFB extraction and retinal detachment
repair, our patient's visual acuity was decreased despite a
successful surgical outcome. Because of the mild anterior
chamber inflammation and retinal hemorrhage observed
OS, there was also suspicion for early sympathetic
ophthalmia. For these reasons, electrophysiology was
performed and revealed a reduction in rod and dark-
adapted cone responses in both eyes, albeit to a much
greater degree OD.
The ERG findings were most consistent with siderosis
OD and were partially reversible with repeat testing.
Contralateral ERG abnormalities have not been reported
in the context of siderosis, but fortunately, these changes
completely reversed on repeat testing. For this reason, the
patient was treated only with routine postoperative medi-
cations, and systemic immunosuppression was deferred.
Prior reports analyzing the heavy metal content of IOFBs
have used diagnostic X-ray spectrometry [12, 13] and the
percentage copper content of an IOFB likely plays a role in
the degree of copper dissemination and associated toxicity.
In one prior patient reported with a copper IOFB, an
undiluted vitreous sample showed an inflammatory reaction
consisting of CD3+ T lymphocytes and polymorphonuclear
leukocytes [13]. Our patient demonstrated moderate in-
flammation prior to PPV/IOFB removal and the low-grade
inflammation in the contralateral eye was suspicious for an
autoimmune reaction. It is not clear whether this repre-
sented early sympathetic ophthalmia, but the inflammation
OS completely resolved without medical therapy. We
hypothesize that, following the initial IOFB injury, the
intraocular inflammation was due to the toxic effects of the
iron fragment. IOFB extraction led to a decrease in
localized ocular inflammation and a resultant improvement
in the ERG findings. The etiology of the contralateral eye
inflammation is not clear; however, the mild anterior
chamber inflammation in the contralateral eye had resolved
at final follow-up.
ICP-MS is an extremely sensitive technique capable of
detecting metal fragments approaching 1 part in 1012 (parts
per trillion) and was extremely valuable in identifying iron
as the predominant heavy metal in the IOFB; copper was
found in minimal quantities. Reversal of ERG abnormali-
ties has been described previously following IOFB extrac-
tion, and based on the patient's clinical course, the patient's
visual prognosis remains favorable. He is under surveil-
lance for the development of sympathetic ophthalmia given
his occult penetrating globe injury.
Conclusion
In summary, ICP-MS and ERG accompanied PPV/IOFB
retinal detachment repair in the successful management of
this patient. The combination of these techniques was also
instrumental in documenting the resolution of retinal
102 J Ophthal Inflamm Infect (2012) 2:99–103
changes, providing prognostic information, and may be
valuable in the medical and surgical management of these
complex cases.
Acknowledgements This research was supported by an unrestricted
grant from the Research to Prevent Blindness (New York, NY) to the
Casey Eye Institute, Oregon Health and Science University, and
Emory Eye Center, Emory University School of Medicine.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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Occult intraocular foreign body masquerading as panuveitis: inductively coupled mass spectrometry and electrophysiologic analysis

Crossref

Chalcosis in the human eye. A clinicopathologic study.

Chalcosis: a study of natural history.

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Improvement of siderotic ERG.

Neumann R,BelkinM,LoewenthalE,GorodetskyR(1992) Alongterm follow-up of metallic intraocular foreign bodies, employing diagnostic X-ray spectrometry.

Occult anterior-chamber metallic fragment post-phacoemulsification masquerading as chronic recalcitrant postoperative inflammation.

Occult intraocular foreign body: ultrasound biomicroscopy holds the key.

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Ocular siderosis. Diagnosis and management.

Reversible retinal toxicity associated with retained intravitreal copper foreign body in the absence of intraocular inflammation.

The Montgomery Lecture 1979. Ocular metallosis.

Two remarkable events in the field of intraocular foreign body: (1) The reversal of siderosis bulbi. (2) The spontaneous extrusion of an intraocular copper foreign body.

Ultrasound biomicroscopy as a tool for detecting and localizing occult foreign bodies after ocular trauma.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3345056

Occult intraocular foreign body masquerading as panuveitis: inductively coupled mass spectrometry and electrophysiologic analysis

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