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CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 62-64

Anterior chamber angle foreign body masquerading as corneal edema


Cornea and Anterior Segment, Visakha Eye Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Submission24-Aug-2021
Date of Decision17-Sep-2021
Date of Acceptance17-Sep-2021
Date of Web Publication01-Nov-2021

Correspondence Address:
Dr. Pandiri Venkatagiri Syamala
Visakha Eye Hospital, Pedda Waltair, Visakhapatnam - 530 017, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jocr.jocr_24_21

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  Abstract 


Open globe injuries (OGIs) with intraocular foreign bodies are a common presentation in ophthalmic practice. Foreign bodies in the angle of the anterior chamber have been described earlier. In this report, two such cases of foreign bodies in the angle, identified on gonioscopy, are described. One case presented with pain and redness of 6-month duration with trauma 3 years ago. Examination revealed corneal edema and a foreign body in the angle. In the other case, early gonioscopy was performed and an angle foreign body was identified. In both cases, the foreign bodies were removed with good visual results. An OGI with a foreign body embedded in the angle was the common feature in both cases which presented as late corneal edema in the first one. Thus, in cases of any OGIs, gonioscopy should be performed as early as possible, so that complications leading to visual loss can be prevented.

Keywords: Corneal edema, foreign body in angle, gonioscopy, intraocular foreign body, open globe injury


How to cite this article:
Syamala PV, Raju RS, Raju C V. Anterior chamber angle foreign body masquerading as corneal edema. J Ophthalmol Clin Res 2021;1:62-4

How to cite this URL:
Syamala PV, Raju RS, Raju C V. Anterior chamber angle foreign body masquerading as corneal edema. J Ophthalmol Clin Res [serial online] 2021 [cited 2021 Dec 4];1:62-4. Available from: http://www.jocr.in/text.asp?2021/1/1/62/329778




  Introduction Top


Penetrating trauma constitutes a significant cause of ocular morbidity. Intraocular foreign bodies (IOFBs) can be detected in 18%–41% of these injuries.[1] In 60%–80% of cases, the entry wound is located at the cornea or corneoscleral junction.[2] IOFBs are localized in the posterior segment in 58%–88% of trauma.[2] Anterior chamber foreign bodies account for only up to 15% of all IOFBs.[3] The course of the disease depends on the size, location, composition, and nature of the foreign body and the host tissue reaction. Although there have been reports of foreign bodies in the angle of the anterior chamber earlier, such late presentations with corneal edema are rare. This report adds to the few existing cases in the literature wherein an angle foreign body masqueraded as late unexplained corneal edema and underscores the importance of a timely gonioscopy in such cases.


  Case Reports Top


Case-1

A 48-year-old male soda maker presented with blurred vision, watering, and photophobia of 6-month duration in the left eye. He was treated with topical antivirals and antibiotics, previously. There was a history of soda bottle injury 3 years ago with redness and pain which responded to treatment in a week. The best-corrected vision was 20/20 and N6 OD, and 20/60 and N18 OS. Intraocular pressures (IOP) were normal. While the right eye was normal in all respects, his left eye showed mild circumcorneal congestion, Descemet's folds, and increased thickness with edema in the inferior half of the cornea in a triangular fashion extending up to the pupillary area [Figure 1]. A full-thickness scar in the superior and outer quadrant of the cornea was seen [Figure 1]. The rest of the cornea was clear with normal-looking endothelium. Lens was clear. Gonioscopy showed a glass foreign body in the inferior angle at 6 o'clock on the iris [Figure 2]. The rest of the iris was normal. There was moderate pigment dispersion in the angle. X-ray of the left orbit did not show any pathology. The posterior segment was normal. The foreign body was removed under local anesthesia by a temporal limbal approach. At 1 month, he was asymptomatic with a significant reduction of corneal edema [Figure 3]. His best-corrected vision improved to 20/40 and N6 in OS.
Figure 1: Corneal edema inferiorly and a scar due to an old trauma superotemporally

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Figure 2: Gonioscopy showing a glass foreign body in the inferior angle

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Figure 3: Resolution of edema following foreign body removal

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Case-2

A 24-year-old mechanic presented to us with redness and blurring of vision in the left eye for 1 week. He was injured with a gas cylinder gauge glass piece 1 week ago. His visual acuity was 20/30 and N6 unaided in the injured eye. On examination, there was circumcorneal congestion and a full-thickness sealed corneal tear in the temporal mid periphery of about 3 mm in size [Figure 4]. The anterior chamber was well formed with 1+ cells. The pupil was round and briskly reacting to light. Iris was normal and the lens was clear. Fundus examination and IOP were normal. Seidel test was negative and the wound was stable. A gonioscopy was performed to check the angle, as the injury was of high velocity and there was a full-thickness scar which led to the suspicion of a possible foreign body. It revealed a glass foreign body on the iris surface in the inferior angle with moderate pigment dispersion [Figure 5] and [Figure 6]. It was removed through a limbal approach, after which the patient was asymptomatic. The right eye was normal.
Figure 4: Inferotemporal full-thickness sealed corneal tear

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Figure 5: Low magnification view of angle Foreign body on gonioscopy

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Figure 6: High magnification view of foreign body

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  Discussion Top


IOFBs may result in a wide range of intraocular pathology and outcomes based on the mechanism of injury, type of foreign body, and subsequent complications. Anterior chamber foreign bodies in penetrating trauma are often overlooked, especially if they are lodged in the angle. The IOFB location depends on several factors. Sharp-edged fragments with high speed usually enter the eye easily.[4] Entrance wounds should be identified if possible, using a Seidel test in all cases of penetrating trauma.[4] In the first case, the patient had corneal edema, was misdiagnosed as microbial keratitis, and was treated with antivirals. This was similar to previous reports wherein there was late unexplained corneal edema following penetrating trauma and misdiagnosis as viral keratitis.[5],[6],[7] Dong et al. reported bullous keratopathy in spite of the removal of the angle foreign body in one of their cases.[8] Due to the inert nature of glass, and relative immobility of the foreign body in the angle, anterior chamber reaction could have been minimal. Furthermore, due to the endothelium's ability to compensate, the presentation might have been delayed. This case showed that localized corneal edema or endothelial dysfunction can be caused by an intraocular foreign body, even when the trauma occurred much earlier. It is believed to be due to the mechanical irritation of the endothelium by the foreign body leading to corneal decompensation and edema.[9] Meticulous history taking and examination would have led to an early diagnosis. An ultrasound biomicroscopy can help in the detection of foreign bodies when their visualization is obscured as in the cases of hyphema.[10]

In the second case, an early gonioscopy was performed as we had significant learning from the first one. This was possible as the entry wound had been sealed at the time of presentation. Immediate identification of the foreign body and its removal was done. Thus, we must have possibly prevented a late corneal decompensation and visual impairment.

In cases of penetrating trauma, IOFBs should be ruled out. The presence of a foreign body in the angle can be detected if a timely gonioscopy is done. However, it should be ensured that the injury is sealed or has been sutured and is stable before attempting a gonioscopy. Care should be taken to prevent infection. Furthermore, unexplained corneal edema should arouse the suspicion of a missed foreign body and a history of trauma should be elicited. This report emphasizes the invaluable role of gonioscopy as a tool in the early detection of angle foreign bodies and the possible prevention of late visual morbidity in cases of penetrating trauma. We must spread knowledge about the hazards of ocular trauma among patients in vulnerable occupations. The use of protective glasses should be encouraged.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wu TT, Kung YH, Sheu SJ, Yang CA. Lens siderosis resulting from a tiny missed intralenticular foreign body. J Chin Med Assoc 2009;72:42-4.  Back to cited text no. 1
    
2.
Khani SC, Mukai S. Posterior segment intraocular foreign bodies. Int Ophthalmol Clin 1995;35:151-61.  Back to cited text no. 2
    
3.
Archer DB, Davies MS, Kanski JJ. Non-metallic foreign bodies in the anterior chamber. Br J Ophthalmol 1969;53:453-6.  Back to cited text no. 3
    
4.
Katz SE. Ocular trauma: Principles and practice. Optom Vis Sci 2003;80:196.  Back to cited text no. 4
    
5.
Segi A, Thilagar SP, Chandran P. Inert angle foreign body with late manifestation. Indian J Ophthalmol 2019;67:1340.  Back to cited text no. 5
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6.
Han ER, Wee WR, Lee JH, Hyon JY. A case of retained graphite anterior chamber foreign body masquerading as stromal keratitis. Korean J Ophthalmol 2011;25:128-31.  Back to cited text no. 6
    
7.
Nukala N, Pappuru RR, Dave VP. Endoscopy-assisted removal of angle foreign body presenting as persistent localised corneal oedema. BMJ Case Rep 2020;13:e233419.  Back to cited text no. 7
    
8.
Dong PN, Duong NT, Cung LX, Huong DN, Ngan ND, Thien CD, et al. Bullous keratopathy secondary to anterior chamber angle foreign body. Open Access Maced J Med Sci 2019;7:4311-5.  Back to cited text no. 8
    
9.
Saar I, Raniel J, Neumann E. Recurrent corneal oedema following late migration of intraocular glass. Br J Ophthalmol 1991;75:188-9.  Back to cited text no. 9
    
10.
Ishikawa H, Schuman JS. Anterior segment imaging: Ultrasound biomicroscopy. Ophthalmol Clin North Am 2004;17:7-20.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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