Missed punctal foreign body: A cause for chronic ocular irritation.

Case Reports

Case 1

A 48-year-old male, financial advisor by occupation, presented with swelling of eyelids, redness, foreign body (FB) sensation, and watering of the right eye for 2 weeks. He gave history of consulting two ophthalmologists but did not get relief. There was no history of any trauma or surgery. He gave a history of cooking in his kitchen the previous night of the onset of symptoms. On examination, there was preseptal cellulitis of the right upper lid with conjunctival congestion [Fig. 1]. Under the slit lamp, a small FB was seen protruding out from the right upper punctum [Fig. 2]. The FB (metallic) was removed [Fig. 3], and the patient was given topical antibiotic-steroid combination, lubricant, and systemic anti-inflammatory medications. All the symptoms subsided subsequently over a few days.

Figure 1

Clinical photo showing preseptal cellulitis of the right eye (Case 1)

Figure 2

Slit lamp image of the right eye with a foreign body in the upper punctum and conjunctival injection (Case 1)

Figure 3

Slit-lamp image showing a shiny foreign body after removal from the upper punctum. On closer inspection, the foreign body was found to be a metallic foreign body (Case 1)

Case 2

A 35-year-old male, office clerk by occupation, presented with FB sensation, redness, and watering of the left eye for 1 week. He had consulted an ophthalmologist, but the symptoms persisted. There was no history of trauma or surgery. He gave a history of working in his garden the previous evening of the onset of symptoms. On examination, there was conjunctival congestion with a FB (metallic) in the left upper punctum [Fig. 4]. It was removed [Fig. 5]. Topical antibiotic and artificial tears were prescribed. The symptoms subsided over a few days.

Figure 4

Slit-lamp image of the left eye with a foreign body in the upper punctum and conjunctival injection (Case 2)

Figure 5

Slit-lamp image showing a shiny foreign body after removal. On closer inspection, the foreign body was found to be a metallic foreign body (Case 2)

Discussion

Eyelashes have been known to get lodged in the lacrimal puncta, meibomian gland orifices, and subconjunctival space.[12345] A punctual FB can cause secondary ocular inflammation.[4] Eyelashes are reported to enter the upper punctum three times more frequently than the lower punctum.[5]

A FB in the punctum can be missed easily and can lead to unnecessary delay in proper treatment leading to chronic ocular irritation to the patients, which happened in our cases. Therefore, our cases highlight the importance of careful history taking of patients working in certain environments where FB entry is likely and thorough slit lamp examination with eversion of the lids to prevent misdiagnosis and inappropriate treatment. Protective glasses are advised for these people.

To the best of our knowledge, this is the first report wherein metallic FBs are reported to be missed punctual foreign bodies causing chronic ocular irritation to the patients.

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Conflicts of interest

There are no conflicts of interest.