Hal 57 Ct scanning can be usefull for identifying any foreign material in the eye or orbit in injuries from sticks

or wood chips. Penetration of the globe is uncommon, but the foreign body can lodge within the periorbital tissues and cause severe inflammatory reaction. MRI is more reliable for detecting non metallic intraorbital or intracranial foregn bodies because wood can have a similar density to the soft tissue of the orbit or brain. Ct scanning also helps in the diagnosis of a closed rupture of the globe before exploration. This is can confirm a discontinuity of the sclera and a possible extraocular location of the lens of the eye subconujungtivally. This is also usefull in conjungtion with ultrasonogrhapy in detecting a double perforation of the globe from stab wounds. In this type of injuries, these investigation will be perform after primary repair Benda Asing logam intraocular The majority of metallic intraocular foreign bodies are magnetic and are usually due to accidents resulting from hammering steel on steel. Machine tool accident result in large steel fragments, whereas explosive injuries and lead pellets result in nonmagnetic intraocular foreign bodies

History Large metallic fragment

These cause a major penetrating eye injury leading to immediate presentation. The foreign body may still be protrunding from the wound, and there may be a loss of vision from lens disruption and major intraocular hemorrhage as well. In eye injuries resulting from an air rifle or shotgun, the distance from the gun and whether a ricochet has occues is significant. Blunt ijuries is the most common presentation, but penetration of the eye can occur, particularly if the gun was shot at close range or after ricoshet, causing deformation of the pellet. The injuries are always associated with major intraocular damage, often with a double perforation

Small metallic fragment

These are usually the result of hammering stel on steel. The patient is aware that something has hit the eye, but there is no discomfort in the early period after injury. Vision may

be normal or slightly reduced. Any symptoms of visual disturbance should be recorded: black or red streak that subsequently break up suggest vitreous floaters from posterior segment involvement. Small intraocular foreign bodies that are asymptomatic can remain undetected, but over the next few days the eye can become increasingly painful and fotophobic with deteriorating vision from intraocular inflammation. This will occur in about 10% of cases and is an argument for removal of small foreign bodies without vitreous hemorrhage within 24 hours of injury. In the absence of inflammation, painless loss of vision can occur over a period of weeks or months from cataract formation if the foreign body has traversed the lens. Magnetic foreign bodies retained in the ciliary body or pars plana region lead to siderosis with failureof accommodation and increasing iris pigmentation, which may benoted by the patient. Gradual visual loss can occur from a siderotic cataract. Night blindess and progressive loss of the visual field is due to posteriorsegment involvement. These patient also present with sudden loss of vision due to rhegmatogenous retinal detachment associated with vitreous degeneration from siderosis.

Initial assessment
Large fragment or ballistic missiles result in an open eye injury with loss of vision and sign of perforation as described earlier. These foreign bodies have a lot of kinetic energy and ricochet internally or cause a double perforation. Major internal hemorrhageoccurs. In these open eye injuries, the initial management involves wound toilet and primary repair. Removal of the foreign body if indicated (steel or brass0 is deferred until a secondary procedure. Smaller fragment are almost always steel, and the presenting features depend on the entry site and the size of the foreign body (table 6-2). Those entering via the cornea or limbus are more likely to end up in a relatively anterior position, whereas those entering via the sclera travel more posteriorly. Fragment where the smallest dimension is larger than 2 mm lead to leaking wound requiring repair, whereas smaller fragments have a self-sealing wound. In posterior segment intraocular foreign bodies, there is a close correlation between an open wound and the occurrence of retinal damage plus vitreous hemorrhage (table 6-3) leading to intraocular fibrosis

Clinical features: entry via the cornea

Entry thourgh the cornea leads to a full thickness wound. A small foreign bodya may be arrested in the deeper layer of the cornea but can project into the anterior chamber or fall into the anterior chamber. With slightly more velocity, the particle may arrest on the iris An intracorneal foreign body can be identifies on the slit lamp in the deeper layers of th stroma. The typical wedge shape of particle off a hammer has a metallic sheen. The particle may protrude into the anterior chamber Tiny particles in the abterior chamber rarelt cause any initial visual disturbance. Slit lamp examination will confirm the presence of a small, full-thickness corneal wound. The particle may be visible on the iris, but if there is no sign of further penetration, gonioscopy should be performed. The foreign body is found at about the 6 oclock position as it falls to the bottom of the anterior chamber. Because these foreign bodies in the anterior chamber are initially pain free with no disturbance of vision, the patient may not present at the time of injury or the object can remain undetected. The patient may present 1or 2 days later with a painful red eye and deteriorating vision due to an acute inflammatory respone. Ciliary injection is present with flare and cells in the anterior chamber, and the intraocular pressure is a elevated. A small, full-thickness wound through the cornea indicates the presence of an intraocular foreign body. A fibrinnous reaction will develop around this object, partially obscuring its metallic nature. Small particles with slightly greater velocity can penetrate the lens. If entry is through the mind-periphery of the cornea, an iris hole will be present. A more central entry can cut the pupil sphincter or miss the iris completely. With these small foreign bodies it is unusual to see any bleeding into the anterior chamber, and the intraocular pressure is normal. Examination on the slit lamp confirms the presence of a small, full-thicknesscorneal wound, and the direction of this give some indication of the trajectory of the particle. After pupil dilatation, the lens is examined. The oresence of a foreign body or a track thourgh the lens will show up as a disturbance of the red reflex. This is confirmed by slit lamp examination. The particle may arrest within the lens or protrude through the posterior capsule. Intralenticular foreign bodies may cause some initial visual disturbance if axial, but they can be asymptomatic. The particle is clearly visible by slit lamp examination. Because it is

isolated within the lens substance, an inflammatory reaction is unusual and siderosis remains confined to the lens. Unless the particle is projecting through the posterior capsule, conservative management is adopted until there is clear evidence of progressive cataract formation. If the particle projects through the posterior capsule there is a risk of developing siderosis. Although conservative management is usually adopted in the first instance if vision remain good, monitoring of electrodiagnostic responses is essential. Passage through the lens absorbs some of the kinetic energy, and small particle ( with a sealed entry wound) fall toward the pars plana or vitreous base region inferiorly. The track through the lens can be identified with an entry and exit wound in the anterior and posterior lens capsule. It is usually possible to see the foreign body in the posterior segment with the indirect ophtalmoscope with indentation the lens can obscure the view. If the presentation is delayed, an inflammatory reaction develops around the foreign body, leading to encapsulation. A reaction in the vitreous will lead to a decrease in vision and may be accompanied by acute inflammation of the anterior segment, leading to a hypopyon uveitis. Larger particles with more kinetic energy will continue in their trajectory across the posterior segment. These larger particles disrupt the lens, making posterior segment examination difficult. They can impact in the retina, exit through the posterior sclera , or ricochet and come to rest in a relatively anterior position. Damage involving the macula is common, and vitreous hemorrhage usually occurs. The entry wound in the cornea and subsequent trajectory can be oblique, and instead of penetrating the lens, the particle can end up in the cilliary body or pars plana region. This is the most common site for missed intraocular foreign body because there is no initial disturbance of vision and no obvious signs of penetration unless examined on the slit lamp. These particles can be confirmed by x-ray examination in fresh injuries and byy use of the Roper-hall electroacoustic locator if available. This instrument is a metal detector that can pinpoint the location of a metallic foreign body, particularly if it is anterior or in retained particles whre the radiodensity is reduce. If presentation is deleyed or the injury missed, one of the following two situation develops. An acute intraocular inflammation can occur, leading to a painful red eye with during the first 24 hours after injury because vitreous hemorrhage does not occur with these small foreign bodies. After this, progressive opafication of

photophobia and deteriorating vision from an acute inflammatory response, or the injury may go undetected, resulting in siderosis. Clinical feature: entry via the limbus or sclera This leads to passage of the foreign body into the posterior segment. The entry wound may be difficult to detecte, but if seen within 24 gours of injury, the conjungitval wound will stain with 0,5% fluoroscein, and a small subconjungtival hemorrhage can occur. The anterior chamber and intraocular pressure are normal unless inflammation supervenes. Even small particles with have sufficient kinetic energy to traverse the vitreous and impact on the retina posteriorly, causing some comotio and localized hemorrhage. They may also exit through the posterior sclera. Larger particles cause extensive damage by ricocheting internally, or a double perforation can occur with retinal incarceration in the exit wound. Vitreous hemorrhage will occur. Retained intraocular foreign bodies Patient with a retained steel foreign body that has been within the eye for over 1 month begin to develop sign of siderosis. Retinal function tests can detect this before any clinical signs become evident. A reduction in the electrooculogram and dark adaptation occur early, followed by shanges to the electroretinogram. Initially the B-wave shows a super-normal response with loss of oscillatory potentials, but as the condition progresses, the electroretinogram deteriorates with a reduction of B-wave, which ultimately becomes extinguished. This result must be interpreted in conjungtion with ultrasonography because coexisting retinal detachment will also affect these tests. The sign of anterior segment siderosis are mydriasis and heterochromia of the iris. Rust spots form a ring of deposits on the anterior lens epithelium in the midperiphery visible after pupil dilation. Elevated intraocular pressure can be feature in some cases, but hypotony is more common from ciliary body failure. Small intraretinal foreign bodies becomes encapsulated and are less likely to cause siderosis compared with preretinal foreign bodies. The develop coarse retinal pigmentation around the foreign body. Although visial acuity can be well preserved until the later stages, the

field of vision is constricted, particularly in relation to the affected retina. Optic disc swelling can also occur, but the etiology of this is obscure. This can lead to unnecessary neurologic investigation if the presence of a retained intraocular foreign body is not suspected. Posterior segment siderosis is also characterized by a degenerate vitreous. This can lead to sudden loss of vison from a rhegmatogenous retinal detachment, a common reason for presentation. Retained copper foreign bodies cause an intense inflammatory reaction within the eye, leading to early presentation. Occasionally a tiny fragment can be retained without an acute inflammatory respone and lead to chalcosis. This is characterized by a metallic sheen to descemets membrane, a sunflower cataract, and vitreous degenartion with glistening deposits on the fibrils and in front of the macula. Visual acuity varies from being well preserved with a normal electroretinogram to severely impaired with a reduced or extinguished electroretinogram. These changes can reverse to some extent if the foreign boy is removed. If retained, periodic episodes of inflammation continue to occur and the foreign body can migrate and eventually extrude. X-ray evaluation With low-velocity injuries and no clinical evidence of a penetrating injury, x-ray examination is not effective method of screening. However, all high-velocity injuries with evidence of or a strong suspicion of an intraocular foreign body should be x-rayed. Most metal fragments are clearly visible on plain x-ray, although some metals are relativelyradiolucen (eg. Almunium). It has been customary to x-ray all sucpected intraocular foreign bodies after a highvelocity injury with multiple views, including both up gaze and down-gaze. This is unnecessary because in most cases there will be evidence of ocular penetration and the foreign body may be visible. A single posteroanterior and lateral orbital x-ray is sufficient to confirm the metallic nature of the foreign body The shape of the foreign body on x-ray is characteristic: steel fragments off a hammer or chisel have a typical wedge or boat shape with regular edge. A ragged fragment with an irregular shape should suggest a softer metal such us brass or lead. There are often deformed during an

explosive injury. Lead pellets retain their configuration if no ricochet has occurred before penetrating the eye or orbit but become flattened after ricochet, making penetratuin more likely. Localization of an intraocular foreign body can be accomplished using plain x-ray and a limbal ring, but this has been largely superseded by Ct scaning. Where Ct scan is not available, the limbal ring method provides a reliable means of locating an intraocular foreign body. Ct Scanning With intraocular metallic particles, CT scanning is useful when the view of posterior segment is obscured because cataract or posterior segment hemorrhage. In most cases scanning will be perform after primary repair. It can determine whether a metallic foreign body is still within the globe or is extraocular after a double perforation. It is important to know wheter a metal fragment is still within the eye before planning secondary surgery. Reflections from the particle cause some interference with the scans, and this technique is most useful for smaller particles. The foreign body can be accurately located in relation to the sclera. Small retained magnetic foreign bodies lose their radiodensity and may not be visible on plain x-ray. Ultrasonography or CT scanning can help detection in this situation PROGNOSIS In important part of the initial management of all penetrating injuries is to explain the xtent of damage and give some indication of recovery. In eye with no light perception or inaccurate projection, the prognosis is poor, but primary repair should always be undertaken. A guarded prognosis is given, but no mention is made at this stage of the possibility of needing to remove the eye to prevent sympathetic ophthalmitis. In injuries confined to the anterior segment, the chances of safe retention of the eye and restoration of vision are good provided that infection does not supervene. The risk of this is small laceration (around 1%) but significantly higher in injuries resulting in an intraocular foreign body, particularly if removal is delayed. Optical defects and possible further surgery, and close orthoptic supervision will be needed in children. This should be explained to parents at an early stage.

Injuries that are confined to the sclera have a good prognosis if they are relatively anterior and not complicated by vitreous hemorrhage or retinal prolapsed. Secondary surgery may be needed to deal with posterior segment complications. Combined anterior and posteriorsegment injuries have the least favorable prognosis, particularly if extensive and associated with intraocular hemorrhage. A guarded prognosis shoul be given, but if the wound is relatively anterior there is the expectation of some visual recovery. The prognosis for intraocular foreign bodies is related to size and the extent of the damage within the eye. Those with a self-sealing wound are from small particles and should retain vision, although later surgery for cataracts may be required. With larger particles, an open wound will need repair, and lens rupture will nedd immediate surgery. Vitreous hemorrhage is common in these injuries, and the reason for delaying removal of the foreign body unti a later time needs to be explained to the patient. The risk of infection and the possibility of posterior segment damage limiting the potential for recovery of good vision must be explained. ACKNOWLEDGMENT The author acknowledgment that many of the illustrations in this chapter have been previously published in Eagling EM, Roper-Hall MJ, Eye injuries: An Illustrated Guide. London: Gower Medical Publising, 1986, and are reproduced by permission from Mosby-year Book Europe Ltd.