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Foreign Bodies in the Anterior Chamber Angle
FOREIGN BODIES IN T H E ANTERIOR CHAMBER ANGLE T H E I R MANAGEMENT WII ¹ T H E AID OF GONIOSCOPY HARVEY E. 'rHORPE,
M.D. Pittsburgh, Pennsylvania
It is the purpose of this article to discuss the examination, diagnosis and management of retained foreign bodies in the anterior chamber angle and to present briefly a few typical selected cases. Special points in tech nique will be discussed. Splinters of foreign material which have lodged in the anterior chamber are, as a rule, quite small and, except for driven-in lashes, are less than two mm in size. The majority are less than one mm in length. Their size and position require precise surgery when splinter removal is contemplated. Gonioscopy is helpful in diagnosis and management. The clinical acumen of the ophthal mologist is challenged from time to time by ocular trauma resulting from mishap in the course of work, play, mischief, combat, au tomobile travel, casual accidents and baffling recurrent inflammation. It is obvious that the presence of a retained intraocular spli nter should be routinely suspected when a history of trauma is elicited. A careful his tory and thorough clinical examination, in cluding roentgenography, should be supple mented by tests with electro-inductive loca tors, skeleton free (soft tissue) X-ray and by gonioscopy. Shattered eyeglass fragments and auto mobile windshields contribute their share of intraocular splinters. Magnetic and nonmag netic metallic particles, bits of stone, grit, eyelashes, wood and thorns may lodge in the angle recess. Minute, chemically inactive particles, such as tiny glass splinters, are usually well tolerated. They need not be dis turbed as long as they cause no irritation. Larger glass splinters because of their size may cause irritation. Steel, iron, brass, cop per and other materials because of their toxicity, even though minute in size, usually cause ocular inflammation. Any intraocular
foreign particle causing irritation obviously requires removal. The presence of a recent or old healed corneal perforation in the absence of an iris hole and lens injury, indicates the advisabil ity of chamber angle investigation. Gonios copy permits the visualization of chamber angle content and is, therefore, a recognized essential for the diagnosis of a foreign body in this location. A simple gonioscope can also be helpful during anterior chamber sur gery and postoperative management. Lis ter's or Swan's gonioscope and Thorpe's* new magnifying surgical goniolens (fig. 1-B) can be used during convalescence without danger of complication. One should add that routine gonioscopy is advisable in all cases of anterior segment pathology. Roentgenography obviously fails to show nonradiopaque splinters and sometimes even misses small metallic particles. It is well known that the skeleton-free X-ray tech nique is often helpful in finding relatively small radiopaque particles. It is much more revealing to combine it with Prof. Hans Goldmann'st corneal localizing ring. Recurrent ocular inflammation of unex plained origin has, in my experience, on a number of occasions been found to be due to an unsuspected retained intraocular for eign body in the chamber angle and other parts of the globe. One of the earliest cases was recorded by Bruce.1 Diagnostic direct gonioscopy can be per formed with the hemispheric Koeppe gonioscopic lens or its modifications. This method provides a good view of the angle. It is somewhat cumbersome because the method necessitates that the patient be in * Made by Ocular Products, Inc., Seattle, Wash ington. t Made by Haag Streit, Berne, Switzerland.
1340/400
HARVEY E. THORPE
handle
Fig. 1 (Thorpe). (A) Lister's goniotomy lens (plexiglass) diame ter-11 mm. (c) Corneal surface. (v) Piano viewing surface. (B) Thorpe's magnifying surgical goniolens (methyl methacrylate) diameter-10 mm, magnification Xl.6, with integral miniature handle. (The lens is self-retained by cap illary attraction. The handle is used only for placement.) (c) Corneal surface, (v) Convex viewing sur face. ( Note : The anterior chamber angle can be viewed through a binocular loupe or microscope with either of these two lenses.)
the supine position. The slitlamp microscope obviously cannot be used with Koeppe type lenses. Gonioscopy can also be performed readily with Lister's and Worst's angular direct gonioscopes or with the magnifying surgical goniolens already mentioned. Indirect gonioscopy (the observation of the chamber angle in the reflecting mirror of the newer gonioscopes) lends itself well to clinic and office practice with the patient sitting at the slitlamp with any of the fol lowing gonioscopes : Goldmann's single mir ror gonioscope made by Haag Streit of Berne, the Allen-Thorpe four-mirror gonioprism made by Bausch and Lomb of Rochester, New York, or Thorpe's* new conical shaped four-mirror diagnostic gon iolens. A four-mirror gonioscope supplied by Zeiss-Opton of Oberkochen and the Von Beuningen goniopyramid made by ZeissJena may be similarly employed. I prefer indirect gonioscopy with the slitlamp microscrope as a routine diagnostic procedure. Anomalies, pathologic changes and foreign bodies are thus readily observed in the cir cumference of the chamber angle recess. One or more foreign bodies may be found in the chamber angle. Their position should * Made by Ocular Products, Inc., Seattle, Wash ington.
be noted on a diagram. Most metallic, glass or stone particles are usually lodged in the inferior angle. Particles may also be lodged in iris crypts or stroma. Thorns in this re gion are usually partly buried in the limbus or neighboring sciera, and may extend into the chamber angle. Materials of low specific gravity such as paraffin particles or ointments which have gained access to the anterior chamber through an operative or accidental wound readily change their position with eye and head movements. Their position at any one time is determined by gravity to be at the zenith of the uppermost meridian. Ointment in the anterior chamber appears in the form of rounded yellowish-gray translucent dro plets. After several weeks, ointment may break up into spawnlike droplets which dot the superior trabecula and angle recess. A fresh foreign body may be hidden by hemorrhage in the angle. Brass and chemi cally active copper particles may be ob scured by a cocoon of exudate which may organize into a peripheral anterior bridge synechia. In the latter case, proximal illumi nation and transillumination by the slitlamp beam are utilized to make a hidden foreign body visible in the gonioscope. One can also observe a transilluminated angle recess with
FOREIGN BODIES IN CHAMBER ANGLE
Thorpe's surgical goniolens already men tioned. Magnetic particles can sometimes be differentiated from nonmagnetic by the pa tient's history, but more easily by test with an electroinductive locator. In my experi ence, the Berman locator has proven to be the most sensitive foreign-body locator in clinical work. SURGICAL PROCEDURE
Preoperative sedation, intravenous Diamox, osmotic agents, akinesia and local an esthesia have been employed as a rule. In recent years, I have depended on intrave nous administration of 25% mannitol solu tion (1 gm mannitol/kilo) for patients under general anesthesia. It is started as soon as the patient is anesthetized. A urethral cath eter is inserted. Patients who are scheduled for local anesthesia are given 1.0 gm of gly cerin/kilo , orally, in orange juice, two hours preoperatively. Two cc of Carbocain are in jected retrobulbarly with immedite orbital digital compression for a period of at least five minutes. These measures result in a very soft eye. Paracentesis of the anterior cham ber is often performed for splinter removal from the vitreous and for ciliary body sur gery, as a globe-softening procedure just prior to uveal incision. The diagnosis having been made, the sur geon must remove the foreign body from the angle in the least traumatic manner. Preoperative miosis is essential. Pilocarpine 2% is instilled. If the particle is magnetic, it can often be dislodged by applying a hand magnet (either a permanent type or an elec tromagnet) to the opposite side of the cornea. This must be done very carefully because a magnetic splinter enmeshed in iris may drag the contiguous iris with it and thus produce hemorrhage and iridodialysis. If the mag netic particle comes free into the anterior chamber, it is released and dropped onto the iris (by pulling the magnet away or by breaking the electric circuit). The splinter is then extracted with the hand magnet through a keratome incision. If the chamber
1341/401
becomes shallow during the incision, it must be restored with physiologic saline before the splinter is extracted. This avoids entan glement in the iris, as well as endothelial damage. Following extraction, toilet of the wound is performed. A small incision need not be sutured. A mydriatic is instilled at the first dressing 24 hours later. Nonmagnetic splinters in the angle and magnetic particles which cannot be dis lodged are best removed from beneath a limbus-based scierai flap, which is made just posterior to the foreign body. This is done after the conjunctival incision is made. The scierai incision is made two mm back of the limbus. It usually is 5-mm long. Its site is monitored by the surgical goniolens set on the cornea. The angle can now be entered at its apex by careful dissection. Sutures of 7-0 silk are preplaced across the scierai inci sion. The chamber angle foreign body can be seen from the one side through the surgi cal goniolens and from the other side under the scierai flap by direct vision. In the case of a magnetic splinter, the magnet tip can be reapplied by direct visual control to the for eign body. Nonmagnetic splinters are grasped with a spoon, a foreign body for ceps or an Arruga capsule forceps. They may need to be gently dissected or teased free. The postlimbal transscleral approach has, in my experience, been more successful and attended by fewer complications than the older transcorneal approach recom mended by Haab and Lancaster. The trans scleral approach is seldom attended by iris prolapse, which is a frequent complication of the transcorneal approach. Toilet of the wound is performed after the foreign body has been removed. The an terior chamber is then re-established with an air bubble. The preplaced silk sutures in the scierai flap are tied, and the conjunctiva is sutured. A dressing is applied. The eye is dressed the following day. Atropine may be instilled. The patient may be discharged two or three days after surgery. The dressing may be left off five days after surgery.
HARVEY E. THORPE
1342/402 C A S E REPORTS CASE 1
R. S., a man aged 21 years, suffered what was thought to be a minor accident to his right eye while hammering an axle at work 12 days pre viously. A foreign body was apparently removed from the right inferior cul-de-sac by a first-aid attendant. The eye became red after a week. Slitlamp examination revealed a corneal perfora tion, positive flare and cells. The iris, lens and retina were intact. Vision was 20/30. Skeletonfree X-ray films gave positive findings. Gonioscopy revealed a minute splinter in the inferior angle at the 5-o'clock position. The Berman lo cator revealed that the minute splinter in the in ferior angle was magnetic. It was dislodged with the Lancaster hand magnet and dropped on the iris. Surgery was performed under local anesthe sia, with akinesia and retrobulbar injection; 500 mg of Diamox was administered intravenously, one hour preoperatively. The foreign body was extracted through a keratome incision. The ante rior chamber was re-established with saline be fore the extraction and again after the magnet application. Toilet of the wound was performed. A patch was applied. The eye was dressed daily and mydriasis was begun 24 hours after surgery. Recovery was uneventful. Postoperative vision was improved to 20/20. CASE 2
R. B., a boy aged eight years (1954), was struck in the left eye by a twig 10 days previous ly. A thorn was seen just behind the limbus. His ophthalmologist attempted removal but did not succeed because particles broke off, leaving the point deeply buried. He was transferred to our care. Vision was 20/40. Gonioscopy revealed that the thorn had penetrated into the inferotemporal anterior chamber angle. The iris, the crystalline lens and the fundus were negative. The patient was operated under general anesthesia. The con junctiva was incised and the sciera bared in the inferotemporal meridian. The site of the incision was monitored with the goniolens and the ciliary body was exposed just posterior to the scierai spur, by turning a limbus-based scierai flap 4-mm long and 2-mm wide. The base of the thorn was now readily seen. It was grasped with pointed foreign-body forceps and easily extracted. The scierai incision was closed with the preplaced sutures. Recovery was uneventful. Final vision was 20/25. CASE 3
P. B., a boy aged 15 years (1963), son of a physician, was referred by his ophthalmologist. The left eye had been injured two days previous ly when a blank cartridge exploled. There was a corneal entry wound on the upper nasal quadrant. He had a piece of copper in the 6-o'clock posi tion of the left anterior chamber angle. The crys
talline lens was intact, as was the retina. X-ray films revealed the foreign body to be 1 by 2 mm, indicating that probably the ciliary body was also involved. Vision was 20/40. Diamox (500 mg) and mannitol (60 gm) were administered in travenously. The patient was operated under general anes thesia. The surgery was monitored with the sur gical gonioscope. The sciera was bared beneath a conjunctival flap. A scierai flap 5-mm long was turned forward three mm behind the limbus in the 6-o'clock meridian, exposing a discolored macerated ciliary body extending up to the chamber angle. Silk scierai sutures were preplaced. Gentle dissection exposed the foreign body which involved the iris root and anterior ciliary body. The macerated portion of the ciliary body was resected exposing the vitreous which did not herniate. The scierai incision was closed with the preplaced sutures. The conjunctiva was sutured. Recovery was sur prisingly uneventful. Vision returned to 20/15 where it has been maintained for the past two years. CASE 4
J. D., a man aged 23 years (1956), was struck in the left eye by a wire while at work. The first-aid nurse instilled an antibiotic ointment and patched his eye. At slitlamp examination in our office one week later, he had a 1.5-mm diameter droplet of ointment in the upper part of the ante rior chamber. The ointment was freely movable. There was a sealed corneal perforation in the pupil zone. Visual acuity was 20/50. The iris, the crystalline lens and retina were normal. He was followed for two weeks, during which period seeding of the superior angle by tiny ointment globules was observed. The eye did not become inflamed. It was thought best to remove the ointment from the anterior chamber. This was accomplished readily. Under local anesthesia, a limbal keratotomy was performed in the 12-o'clock meridian, thus evacuating the small ball of oint ment. Convalescence was uneventful. Vision after recovery was limited to 20/40, due to corneal scar. There were no unusual developments. Tension did not become elevated. CASE 5
J. S., a girl aged 17 years (1961), injured her left eye in 1956 when a dart struck her spectacles and broke her glasses, causing perforation of the cornea and glass in the chamber angle. She was operated by her ophthalmologist in another state. Three attempts at removal of glass from her chamber angle were made by him in 1956, 1957 and 1958. She was referred to my care in August, 1961, because of corneal edema and recurrent inflammation of the left eye. Vision, O.S., was 20/50 with glasses. A glass splinter was seen by gonioscopy at the 6-o'clock position, with adjacent peripheral anterior synechia. Diamox (500 mg) was given intravenously
FOREIGN BODIES IN CHAMBER ANGLE before the general anesthetic. The glass splinter was removed in August, 1961, beneath a scierai flap in the 6-o'clock position. A peripheral iridectomy was also performed. The eye continued to have periods of irritation and corneal edema. Further study revealed an ad ditional fragment of glass which was not pre viously seen. She was reoperated on April 26, 1962, and a second piece of glass was extract ed, under a limbus-based scierai flap, from a site at the S-o'clock position adjacent to the previous surgery. On May 10, 1962, the conjunctival flap was revised. Hypotony during glass removal was maintained by adding curare intravenously in ad dition to the general anesthesia. The patient made a good recovery, except for rare periods of redness of the left eye. Vision came up to 20/15 with correction. Follow-up in 1963 revealed no late sequelae.
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pressure applied over the closed lids onto the orbit. Preoperative sedation usually con sisted of oral pentobarbital and 50 to 100 mg of Demerol® given intravenously. Man nitol and glycerin are useful as osmotic agents for hypotony. Diamox (500 m g ) in travenously one hour before surgery also helps to produce hypotony. CONCLUSION
T h e diagnosis and surgical removal of foreign bodies from the anterior chamber angle beneath a scierai limbus-based flap, as aided by gonioscopy, were described. Five selected cases were presented.
SUMMARY
T h e prognosis is favorable in chamberangle foreign bodies, if they are removed fairly promptly and removal is uncompli cated by lens injury or infection. An occa sional case may present complications be cause it was not possible to see a second ob scured foreign body, as in Case 5. In Case 3, a resection of a small sector of ciliary body was essential because of maceration by toxic materials from a brass splinter. Ocular hy potony was accomplished when general anes thesia was used by intravenous Diamox, in travenous curare, and, more recently, by in travenous mannitol. An in-dwelling cathe ter is advisable when mannitol is adminis tered intravenously to prevent bladder dila tation during the operation. Local anesthesia was usually combined with retrobulbar in jection of Carbocain 2 % and firm digital
OPHTHALMIC
3600 Forbes Avenue
(13).
NOTE: In the cases reported herein, the AllenThorpe four-mirror gonioprism was used in clinical examination and the Lister surgical goniolens was employed during surgery. REFERENCES
1. Allen, L, Braley, A. E., and Thorpe, H. E. : An improved gonioscopic contact prism. Arch. Ophth. 51:451, 1954. 2. v. Beuningen, E. : Atlas Spaltlampengonioskopie. Leipzig, Thieme, 1955. 3. Bruce, G. M. : Visualization of foreign bodies in the iridocorneal angle. Arch. Ophth. 10:615, 1933. 4. Goldmann, H. : Ophthalmologica, 96:90, 1938. 5. Goldmann, H., and Bangerter, A. : Ophthal mologica, 101:215, 1941. 6. Lister, A.: Brit. J. Ophth. 35:505, 1951. 7. Swan, K. C. : Goniotomy : A modified lens and technique. Arch. Ophth., 74:231, 1965. 8. Thorpe, H. : Tr. Am. Acad. Ophth. Otolaryng., in press. 9. Worst, T. G. F. : Direct and indirect image gonioscopy. Am. J. Ophth., 54 :243, 1962.
MINIATURE
Letters, however small and dim, are comparatively large and distinct when seen through a glass globe filled with water. Seneca, Quaestiones Naturales (about 50 A.D.) From, Clarke, J. : Physical Science in the Time of Nero London, Macmillan, 1910, p. 29
M.D. Pittsburgh, Pennsylvania
It is the purpose of this article to discuss the examination, diagnosis and management of retained foreign bodies in the anterior chamber angle and to present briefly a few typical selected cases. Special points in tech nique will be discussed. Splinters of foreign material which have lodged in the anterior chamber are, as a rule, quite small and, except for driven-in lashes, are less than two mm in size. The majority are less than one mm in length. Their size and position require precise surgery when splinter removal is contemplated. Gonioscopy is helpful in diagnosis and management. The clinical acumen of the ophthal mologist is challenged from time to time by ocular trauma resulting from mishap in the course of work, play, mischief, combat, au tomobile travel, casual accidents and baffling recurrent inflammation. It is obvious that the presence of a retained intraocular spli nter should be routinely suspected when a history of trauma is elicited. A careful his tory and thorough clinical examination, in cluding roentgenography, should be supple mented by tests with electro-inductive loca tors, skeleton free (soft tissue) X-ray and by gonioscopy. Shattered eyeglass fragments and auto mobile windshields contribute their share of intraocular splinters. Magnetic and nonmag netic metallic particles, bits of stone, grit, eyelashes, wood and thorns may lodge in the angle recess. Minute, chemically inactive particles, such as tiny glass splinters, are usually well tolerated. They need not be dis turbed as long as they cause no irritation. Larger glass splinters because of their size may cause irritation. Steel, iron, brass, cop per and other materials because of their toxicity, even though minute in size, usually cause ocular inflammation. Any intraocular
foreign particle causing irritation obviously requires removal. The presence of a recent or old healed corneal perforation in the absence of an iris hole and lens injury, indicates the advisabil ity of chamber angle investigation. Gonios copy permits the visualization of chamber angle content and is, therefore, a recognized essential for the diagnosis of a foreign body in this location. A simple gonioscope can also be helpful during anterior chamber sur gery and postoperative management. Lis ter's or Swan's gonioscope and Thorpe's* new magnifying surgical goniolens (fig. 1-B) can be used during convalescence without danger of complication. One should add that routine gonioscopy is advisable in all cases of anterior segment pathology. Roentgenography obviously fails to show nonradiopaque splinters and sometimes even misses small metallic particles. It is well known that the skeleton-free X-ray tech nique is often helpful in finding relatively small radiopaque particles. It is much more revealing to combine it with Prof. Hans Goldmann'st corneal localizing ring. Recurrent ocular inflammation of unex plained origin has, in my experience, on a number of occasions been found to be due to an unsuspected retained intraocular for eign body in the chamber angle and other parts of the globe. One of the earliest cases was recorded by Bruce.1 Diagnostic direct gonioscopy can be per formed with the hemispheric Koeppe gonioscopic lens or its modifications. This method provides a good view of the angle. It is somewhat cumbersome because the method necessitates that the patient be in * Made by Ocular Products, Inc., Seattle, Wash ington. t Made by Haag Streit, Berne, Switzerland.
1340/400
HARVEY E. THORPE
handle
Fig. 1 (Thorpe). (A) Lister's goniotomy lens (plexiglass) diame ter-11 mm. (c) Corneal surface. (v) Piano viewing surface. (B) Thorpe's magnifying surgical goniolens (methyl methacrylate) diameter-10 mm, magnification Xl.6, with integral miniature handle. (The lens is self-retained by cap illary attraction. The handle is used only for placement.) (c) Corneal surface, (v) Convex viewing sur face. ( Note : The anterior chamber angle can be viewed through a binocular loupe or microscope with either of these two lenses.)
the supine position. The slitlamp microscope obviously cannot be used with Koeppe type lenses. Gonioscopy can also be performed readily with Lister's and Worst's angular direct gonioscopes or with the magnifying surgical goniolens already mentioned. Indirect gonioscopy (the observation of the chamber angle in the reflecting mirror of the newer gonioscopes) lends itself well to clinic and office practice with the patient sitting at the slitlamp with any of the fol lowing gonioscopes : Goldmann's single mir ror gonioscope made by Haag Streit of Berne, the Allen-Thorpe four-mirror gonioprism made by Bausch and Lomb of Rochester, New York, or Thorpe's* new conical shaped four-mirror diagnostic gon iolens. A four-mirror gonioscope supplied by Zeiss-Opton of Oberkochen and the Von Beuningen goniopyramid made by ZeissJena may be similarly employed. I prefer indirect gonioscopy with the slitlamp microscrope as a routine diagnostic procedure. Anomalies, pathologic changes and foreign bodies are thus readily observed in the cir cumference of the chamber angle recess. One or more foreign bodies may be found in the chamber angle. Their position should * Made by Ocular Products, Inc., Seattle, Wash ington.
be noted on a diagram. Most metallic, glass or stone particles are usually lodged in the inferior angle. Particles may also be lodged in iris crypts or stroma. Thorns in this re gion are usually partly buried in the limbus or neighboring sciera, and may extend into the chamber angle. Materials of low specific gravity such as paraffin particles or ointments which have gained access to the anterior chamber through an operative or accidental wound readily change their position with eye and head movements. Their position at any one time is determined by gravity to be at the zenith of the uppermost meridian. Ointment in the anterior chamber appears in the form of rounded yellowish-gray translucent dro plets. After several weeks, ointment may break up into spawnlike droplets which dot the superior trabecula and angle recess. A fresh foreign body may be hidden by hemorrhage in the angle. Brass and chemi cally active copper particles may be ob scured by a cocoon of exudate which may organize into a peripheral anterior bridge synechia. In the latter case, proximal illumi nation and transillumination by the slitlamp beam are utilized to make a hidden foreign body visible in the gonioscope. One can also observe a transilluminated angle recess with
FOREIGN BODIES IN CHAMBER ANGLE
Thorpe's surgical goniolens already men tioned. Magnetic particles can sometimes be differentiated from nonmagnetic by the pa tient's history, but more easily by test with an electroinductive locator. In my experi ence, the Berman locator has proven to be the most sensitive foreign-body locator in clinical work. SURGICAL PROCEDURE
Preoperative sedation, intravenous Diamox, osmotic agents, akinesia and local an esthesia have been employed as a rule. In recent years, I have depended on intrave nous administration of 25% mannitol solu tion (1 gm mannitol/kilo) for patients under general anesthesia. It is started as soon as the patient is anesthetized. A urethral cath eter is inserted. Patients who are scheduled for local anesthesia are given 1.0 gm of gly cerin/kilo , orally, in orange juice, two hours preoperatively. Two cc of Carbocain are in jected retrobulbarly with immedite orbital digital compression for a period of at least five minutes. These measures result in a very soft eye. Paracentesis of the anterior cham ber is often performed for splinter removal from the vitreous and for ciliary body sur gery, as a globe-softening procedure just prior to uveal incision. The diagnosis having been made, the sur geon must remove the foreign body from the angle in the least traumatic manner. Preoperative miosis is essential. Pilocarpine 2% is instilled. If the particle is magnetic, it can often be dislodged by applying a hand magnet (either a permanent type or an elec tromagnet) to the opposite side of the cornea. This must be done very carefully because a magnetic splinter enmeshed in iris may drag the contiguous iris with it and thus produce hemorrhage and iridodialysis. If the mag netic particle comes free into the anterior chamber, it is released and dropped onto the iris (by pulling the magnet away or by breaking the electric circuit). The splinter is then extracted with the hand magnet through a keratome incision. If the chamber
1341/401
becomes shallow during the incision, it must be restored with physiologic saline before the splinter is extracted. This avoids entan glement in the iris, as well as endothelial damage. Following extraction, toilet of the wound is performed. A small incision need not be sutured. A mydriatic is instilled at the first dressing 24 hours later. Nonmagnetic splinters in the angle and magnetic particles which cannot be dis lodged are best removed from beneath a limbus-based scierai flap, which is made just posterior to the foreign body. This is done after the conjunctival incision is made. The scierai incision is made two mm back of the limbus. It usually is 5-mm long. Its site is monitored by the surgical goniolens set on the cornea. The angle can now be entered at its apex by careful dissection. Sutures of 7-0 silk are preplaced across the scierai inci sion. The chamber angle foreign body can be seen from the one side through the surgi cal goniolens and from the other side under the scierai flap by direct vision. In the case of a magnetic splinter, the magnet tip can be reapplied by direct visual control to the for eign body. Nonmagnetic splinters are grasped with a spoon, a foreign body for ceps or an Arruga capsule forceps. They may need to be gently dissected or teased free. The postlimbal transscleral approach has, in my experience, been more successful and attended by fewer complications than the older transcorneal approach recom mended by Haab and Lancaster. The trans scleral approach is seldom attended by iris prolapse, which is a frequent complication of the transcorneal approach. Toilet of the wound is performed after the foreign body has been removed. The an terior chamber is then re-established with an air bubble. The preplaced silk sutures in the scierai flap are tied, and the conjunctiva is sutured. A dressing is applied. The eye is dressed the following day. Atropine may be instilled. The patient may be discharged two or three days after surgery. The dressing may be left off five days after surgery.
HARVEY E. THORPE
1342/402 C A S E REPORTS CASE 1
R. S., a man aged 21 years, suffered what was thought to be a minor accident to his right eye while hammering an axle at work 12 days pre viously. A foreign body was apparently removed from the right inferior cul-de-sac by a first-aid attendant. The eye became red after a week. Slitlamp examination revealed a corneal perfora tion, positive flare and cells. The iris, lens and retina were intact. Vision was 20/30. Skeletonfree X-ray films gave positive findings. Gonioscopy revealed a minute splinter in the inferior angle at the 5-o'clock position. The Berman lo cator revealed that the minute splinter in the in ferior angle was magnetic. It was dislodged with the Lancaster hand magnet and dropped on the iris. Surgery was performed under local anesthe sia, with akinesia and retrobulbar injection; 500 mg of Diamox was administered intravenously, one hour preoperatively. The foreign body was extracted through a keratome incision. The ante rior chamber was re-established with saline be fore the extraction and again after the magnet application. Toilet of the wound was performed. A patch was applied. The eye was dressed daily and mydriasis was begun 24 hours after surgery. Recovery was uneventful. Postoperative vision was improved to 20/20. CASE 2
R. B., a boy aged eight years (1954), was struck in the left eye by a twig 10 days previous ly. A thorn was seen just behind the limbus. His ophthalmologist attempted removal but did not succeed because particles broke off, leaving the point deeply buried. He was transferred to our care. Vision was 20/40. Gonioscopy revealed that the thorn had penetrated into the inferotemporal anterior chamber angle. The iris, the crystalline lens and the fundus were negative. The patient was operated under general anesthesia. The con junctiva was incised and the sciera bared in the inferotemporal meridian. The site of the incision was monitored with the goniolens and the ciliary body was exposed just posterior to the scierai spur, by turning a limbus-based scierai flap 4-mm long and 2-mm wide. The base of the thorn was now readily seen. It was grasped with pointed foreign-body forceps and easily extracted. The scierai incision was closed with the preplaced sutures. Recovery was uneventful. Final vision was 20/25. CASE 3
P. B., a boy aged 15 years (1963), son of a physician, was referred by his ophthalmologist. The left eye had been injured two days previous ly when a blank cartridge exploled. There was a corneal entry wound on the upper nasal quadrant. He had a piece of copper in the 6-o'clock posi tion of the left anterior chamber angle. The crys
talline lens was intact, as was the retina. X-ray films revealed the foreign body to be 1 by 2 mm, indicating that probably the ciliary body was also involved. Vision was 20/40. Diamox (500 mg) and mannitol (60 gm) were administered in travenously. The patient was operated under general anes thesia. The surgery was monitored with the sur gical gonioscope. The sciera was bared beneath a conjunctival flap. A scierai flap 5-mm long was turned forward three mm behind the limbus in the 6-o'clock meridian, exposing a discolored macerated ciliary body extending up to the chamber angle. Silk scierai sutures were preplaced. Gentle dissection exposed the foreign body which involved the iris root and anterior ciliary body. The macerated portion of the ciliary body was resected exposing the vitreous which did not herniate. The scierai incision was closed with the preplaced sutures. The conjunctiva was sutured. Recovery was sur prisingly uneventful. Vision returned to 20/15 where it has been maintained for the past two years. CASE 4
J. D., a man aged 23 years (1956), was struck in the left eye by a wire while at work. The first-aid nurse instilled an antibiotic ointment and patched his eye. At slitlamp examination in our office one week later, he had a 1.5-mm diameter droplet of ointment in the upper part of the ante rior chamber. The ointment was freely movable. There was a sealed corneal perforation in the pupil zone. Visual acuity was 20/50. The iris, the crystalline lens and retina were normal. He was followed for two weeks, during which period seeding of the superior angle by tiny ointment globules was observed. The eye did not become inflamed. It was thought best to remove the ointment from the anterior chamber. This was accomplished readily. Under local anesthesia, a limbal keratotomy was performed in the 12-o'clock meridian, thus evacuating the small ball of oint ment. Convalescence was uneventful. Vision after recovery was limited to 20/40, due to corneal scar. There were no unusual developments. Tension did not become elevated. CASE 5
J. S., a girl aged 17 years (1961), injured her left eye in 1956 when a dart struck her spectacles and broke her glasses, causing perforation of the cornea and glass in the chamber angle. She was operated by her ophthalmologist in another state. Three attempts at removal of glass from her chamber angle were made by him in 1956, 1957 and 1958. She was referred to my care in August, 1961, because of corneal edema and recurrent inflammation of the left eye. Vision, O.S., was 20/50 with glasses. A glass splinter was seen by gonioscopy at the 6-o'clock position, with adjacent peripheral anterior synechia. Diamox (500 mg) was given intravenously
FOREIGN BODIES IN CHAMBER ANGLE before the general anesthetic. The glass splinter was removed in August, 1961, beneath a scierai flap in the 6-o'clock position. A peripheral iridectomy was also performed. The eye continued to have periods of irritation and corneal edema. Further study revealed an ad ditional fragment of glass which was not pre viously seen. She was reoperated on April 26, 1962, and a second piece of glass was extract ed, under a limbus-based scierai flap, from a site at the S-o'clock position adjacent to the previous surgery. On May 10, 1962, the conjunctival flap was revised. Hypotony during glass removal was maintained by adding curare intravenously in ad dition to the general anesthesia. The patient made a good recovery, except for rare periods of redness of the left eye. Vision came up to 20/15 with correction. Follow-up in 1963 revealed no late sequelae.
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pressure applied over the closed lids onto the orbit. Preoperative sedation usually con sisted of oral pentobarbital and 50 to 100 mg of Demerol® given intravenously. Man nitol and glycerin are useful as osmotic agents for hypotony. Diamox (500 m g ) in travenously one hour before surgery also helps to produce hypotony. CONCLUSION
T h e diagnosis and surgical removal of foreign bodies from the anterior chamber angle beneath a scierai limbus-based flap, as aided by gonioscopy, were described. Five selected cases were presented.
SUMMARY
T h e prognosis is favorable in chamberangle foreign bodies, if they are removed fairly promptly and removal is uncompli cated by lens injury or infection. An occa sional case may present complications be cause it was not possible to see a second ob scured foreign body, as in Case 5. In Case 3, a resection of a small sector of ciliary body was essential because of maceration by toxic materials from a brass splinter. Ocular hy potony was accomplished when general anes thesia was used by intravenous Diamox, in travenous curare, and, more recently, by in travenous mannitol. An in-dwelling cathe ter is advisable when mannitol is adminis tered intravenously to prevent bladder dila tation during the operation. Local anesthesia was usually combined with retrobulbar in jection of Carbocain 2 % and firm digital
OPHTHALMIC
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(13).
NOTE: In the cases reported herein, the AllenThorpe four-mirror gonioprism was used in clinical examination and the Lister surgical goniolens was employed during surgery. REFERENCES
1. Allen, L, Braley, A. E., and Thorpe, H. E. : An improved gonioscopic contact prism. Arch. Ophth. 51:451, 1954. 2. v. Beuningen, E. : Atlas Spaltlampengonioskopie. Leipzig, Thieme, 1955. 3. Bruce, G. M. : Visualization of foreign bodies in the iridocorneal angle. Arch. Ophth. 10:615, 1933. 4. Goldmann, H. : Ophthalmologica, 96:90, 1938. 5. Goldmann, H., and Bangerter, A. : Ophthal mologica, 101:215, 1941. 6. Lister, A.: Brit. J. Ophth. 35:505, 1951. 7. Swan, K. C. : Goniotomy : A modified lens and technique. Arch. Ophth., 74:231, 1965. 8. Thorpe, H. : Tr. Am. Acad. Ophth. Otolaryng., in press. 9. Worst, T. G. F. : Direct and indirect image gonioscopy. Am. J. Ophth., 54 :243, 1962.
MINIATURE
Letters, however small and dim, are comparatively large and distinct when seen through a glass globe filled with water. Seneca, Quaestiones Naturales (about 50 A.D.) From, Clarke, J. : Physical Science in the Time of Nero London, Macmillan, 1910, p. 29