Dual intravitreal foreign body: Intravitreal cilia in penetrating injury.

Intraocular cilia, though a rare condition, has been previously reported in cases of open globe injury. We discuss a unique case of intravitreal cilia, found incidentally during vitrectomy for intravitreal foreign body removal.

Introduction

A 24-year-old male presented to our outpatient department after primary scleral perforation repair of the Right eye (RE) 10 days back following hammer chisel injury. On examination, best-corrected visual acuity in RE was hand motions close to face with an accurate projection of rays in all four quadrants while left eye (LE) was 6/6. Slit lamp examination confirmed the temporal repaired scleral wound in RE. The rest of the RE anterior segment and LE were within normal limits. Intraocular pressure was normal bilaterally. Fundus examination of RE revealed fresh vitreous hemorrhage and normal LE. Considering the mechanism of injury, X-ray of orbits and sonography were performed which revealed a metallic intraocular foreign body (IOFB) subsequently localized by computerized tomography scans to the posterior part of the vitreous cavity, measuring 8.2 mm × 6.4 mm and incarcerated in the retina. The patient was advised pars plana vitrectomy with prophylactic encirclage for removal of the foreign body.

After inducing posterior vitreous detachment and completing vitrectomy, a cilia was noted floating near the foreign body [Figure 1]. Internal limiting membrane (ILM) forceps was used to levitate the eyelash to anterior vitreous cavity and subsequently another ILM forceps was used to align and remove the cilia by “handshake” technique through the other port [Figure 2]. This was followed by uneventful removal of the foreign body through the enlarged scleral port and further completion of surgery.

Figure 1

Cilia placed upon the intravitreal metallic foreign body

Figure 2

Cilia grasped with two internal limiting membrane forceps in the anterior vitreous cavity using the “handshake” technique

Discussion

Intraocular cilia is a very rare condition faced by an ophthalmic surgeon. As opposed to the case of our patient, such eyelashes are thought to be more frequently associated with slow-moving foreign bodies such as wire, because the slow speed of the projectile allows for the closure of the eye lids at the time of globe penetration.[1] Intraocular cilia are found mostly in the anterior segment, and its occurrence posteriorly is even more unusual.[2] In our case, the dual intravitreal foreign body that is cilia with an IOFB was detected incidentally during surgery. Such a scenario has not been reported thus far.

No investigative modality can detect intravitreal cilia, and the therapeutic decision is solely clinical.[3] Such cilia although usually indolent can present as acute or delayed inflammation even after 30 years.[4] Intraocular cilia if clinically not visible should be suspected when associated with recurrent inflammation or persistent uveitis, anterior or posterior. In the modern day era with safer instrumentation for vitrectomy, removal of solitary cilia should be considered in asymptomatic patients where surgical extraction can be achieved without harm. In our case, preoperatively there was nothing to suggest the presence of cilia inside the eye and the decision for surgery was easy due to the presence of metallic IOFB.

Intraocular cilia is a challenge, both diagnostically and surgically. Retrospectively, we believe that removal of cilia can be attempted more easily with an end grasping forceps as ILM forceps allow the cilia to slip. Handshake technique is a good option to align the cilia [Figure 2] as such a thin, and malleable structure may get dislodged from the forceps’ grip in the event of forceful removal from the scleral port.

Intravitreal cilia thus is an extremely uncommon situation that requires meticulous preoperative and surgical management. To the best of our knowledge, this is the first report of intravitreal cilia simultaneously with the intravitreal foreign body in the currently documented literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.