ORIGINAL PAPER

Spectrum of intra-ocular foreign bodies and the outcomeof their management in Brunei Darussalam

Joshua George • Nadir Ali • Noor Affizan Rahman •

Nayan Joshi

Received: 20 June 2012 / Accepted: 26 November 2012 / Published online: 11 December 2012

� Springer Science+Business Media Dordrecht 2012

Abstract To review the etiologies, prognostic fac-

tors and treatment outcomes of intraocular foreign

bodies (IOFBs) occurring in the population of Brunei

Darussalam, and provide guidelines to prevent and

manage such injuries. A retrospective review was

performed for all cases of traumatic IOFBs managed in

our centre during a 3-year period between May 2008

and April 2011. The mechanism of injury, manage-

ment, complications and visual outcomes were ana-

lyzed. Majority of the patients were males (93 %) and

the mean age was 36 years. The main causes of trauma

were metal hammering and grass cutting (43 % each).

Other causes include road traffic accidents and fire-

cracker explosion (7 % each). The visual outcome was

C6/18 in 50 % and ‘No perception of light’ in 29 %.

Causes of poor visual outcome were retinal detachment

with proliferative vitreoretinopathy (21 %), endoph-

thalmitis (21 %) and globe maceration (7 %). Prog-

nostic factors associated with significantly worse final

visual outcome included posterior location of the IOFB

(p = 0.05) and larger IOFB size (p \ 0.001). The time

from injury to surgery did not correlate with a worse

visual prognosis. In Brunei Darussalam, the common-

est causes of IOFBs are hammering metal and cutting

grass using power tools. The visual outcome varies

between 6/6 and NPL. Poor visual outcome is related to

the severity of the initial ocular injury, posterior

segment IOFB and endophthalmitis.

Keywords Intra-ocular foreign bodies � Ocular

trauma � Proliferative vitreoretinopathy �Endophthalmitis

Introduction

Ocular trauma is an important, preventable, world-

wide public health problem [1]. Intraocular foreign

bodies (IOFBs) have been reported in almost 40 % of

penetrating ocular injuries [2–4]. They are rather

variable in etiology, presentation, outcome, and prog-

nosis. The damage caused by an IOFB may depend on

several factors, including the size, the shape, and the

momentum of the object at the time of impact, as well

as the site of ocular penetration [5, 6]. In addition to

the initial damage caused at the time of impact, the risk

of endophthalmitis and subsequent scarring (e.g,

proliferative vitreoretinopathy [PVR]) play an impor-

tant role in the planning of the surgical management

and the visual outcome [7]. With modern and

advanced surgical techniques, the outcome and the

prognosis for these potentially devastating injuries

have substantially improved over the years [8].

However, IOFBs still continue to pose a threat of

unilateral blindness.

In this retrospective study, we review the etiologies,

varied presentations, prognostic factors and treatment

outcome of penetrating ocular trauma with retained

J. George (&) � N. Ali � N. A. Rahman � N. Joshi

Ophthalmology Department, RIPAS Hospital,

Bandar Seri Begawan BA1710, Brunei Darussalam

e-mail: drgeorge66@yahoo.co.in

123

Int Ophthalmol (2013) 33:277–284

DOI 10.1007/s10792-012-9687-1

IOFBs occurring in the population of Brunei Darussa-

lam. To the best of our knowledge, there is no such

data published from Brunei Darussalam so far.

From a public health and injury prevention per-

spective, the information obtained from this study may

contribute to the formulation and implementation of

guidelines to prevent such injuries, develop effective

plans for disseminating eye injury prevention materi-

als to the public and to earmark adequate funding for

these initiatives. The data from this study may also be

utilized to explain and to discuss the management

options and the expected outcome to the patients

during the pre-operative counseling.

Materials and methods

The medical records of all cases of penetrating ocular

trauma with retained IOFBs presenting to the eye

department at RIPAS Hospital in the period between

1st May 2008 and 31st April 2011 were retrospectively

reviewed. The minimum follow-up period was 6 months.

Variables in the study included age, sex, nationality,

occupation, date and cause of the injury, circumstance

of the injury, time between injury and presentation,

initial and final best-corrected (c) visual acuity,

afferent pupillary defect, wearing of any protective

eyewear, site of entry of the IOFB, size and number of

IOFBs, composition of the foreign bodies (FBs), time

from injury to surgery, surgical procedures performed,

complications and visual outcome. Causes of visual

loss were also investigated.

Imaging studies included plain x-rays, ocular

ultrasonography, and computerised tomography (CT)

scans, to locate and evaluate the IOFBs. Keratometry

and biometry of the injured eyes were done where

possible. When not feasible on the injured eye, fellow

eye measurements were used.

Systemic (IV Ciprofloxacin 400 mg bid) and top-

ical antibiotic therapy (Gutt. Ciprofloxacin) were

started prior to the surgical intervention. All the

primary surgeries were performed under general

anesthesia. Any corneal lacerations were repaired

with 10-0 nylon sutures without glue. Scleral wounds

were closed from anterior to posterior using 6-0 vicryl

interrupted sutures.

When the IOFB was located within the lens, the

surgical technique involved preservation of as much of

the anterior capsule as possible, with removal of the

IOFB through a limbal entry, followed by cataract

extraction using phacoemulsification with an in-the-

bag or sulcus supported intra-ocular lens. In cases

where the IOFB had gone through the lens and

embedded in the retina, the lens was removed by

either extracapsular cataract extraction or phacoemul-

sification, retaining as much of the anterior and

posterior capsules as possible. The combination of a

standard 3-port 20-gauge pars plana vitrectomy with a

noncontact wide-field viewing system, xenon illumi-

nation, and IOFB forceps was used to remove the

IOFB. Metallic IOFBs lying on the retina were lifted

off the retina using a Grieshaber (Alcon Grieshaber

AG; Schafhausen, Switzerland) positive action IOFB

magnet, brought to the anterior vitreous cavity and then

retrieved with 20-gauge intraocular forceps introduced

through the second port. Perfluorocarbon liquids were

used to protect the posterior part of retina for an

accidental falling of the foreign body during this

procedure. Nonmagnetic small IOFBs were retrieved

with the 20-gauge intraocular forceps. After removal of

the IOFB, the posterior hyaloid was removed and the

vitrectomy completed. Where necessary the sclerot-

omy was enlarged to facilitate easy removal of the FB.

Endolaser was applied around any retinal injury site

and intraocular gas, either sulfur hexafluoride (SF6) or

perfluoropropane (C3F8), was used as tamponade. In

these cases, posterior chamber intra-ocular lens was

implanted over the anterior capsular rim (sulcus

situated) at a later date as a secondary procedure.

Silicone oil was used in the more severe IOFB-related

retinal detachments (RDs) and perforating injuries for

long-term tamponade to prevent the effects of PVR.

Sclerotomies were closed with 6-0 vicryl, conjunctiva

with 8-0 vicryl and 2 mg dexamethasone and 2 mg

gentamicin sulphate were injected sub-conjunctivally.

Intravitreal antibiotics vancomycin 1.0 mg/0.1 mL

and ceftazidime 2.25 mg/0.1 mL were injected at the

end of surgery for cases of intraoperative vitreous

samples with organisms on gram staining or with

evidence of preoperative clinical endophthalmitis.

Postoperatively all patients received systemic cip-

rofloxacin, topical antibiotics and steroids. In each

case recording of best corrected visual acuity (BCVA),

intraocular pressure measurement, slit-lamp biomi-

croscopy and indirect ophthalmoscopy were done.

Causes of decreased vision were assessed considering

site of entry of FB, site of lodgment of FB and

postoperative complications in each case. Culture of

278 Int Ophthalmol (2013) 33:277–284

123

an IOFB or a sample of vitreous was done if an

infection was suspected. In all the cases, the IOFBs

were removed during the first surgery, except one

child with a plastic IOFB which was not visible on X

rays and CT scan initially, but appeared later (after

primary repair) on B-scan ultrasonography, requiring

a subsequent operation to remove the foreign body’’

The minimum follow-up period was 6 months and the

maximum 20 months with the mean 10 months.

The data collected were analyzed using SPSS

version 15.0 programme. Descriptive, correlational

and regression analyses were the main tests used.

Paired-sample T test was used to compare preopera-

tive and postoperative visual acuities for statistically

significant difference.

Results

Of the 14 patients included in this study, 13 were males

(93 %) and only one patient was female. Half of the

patients were foreigners. The age ranged from 9 to

53 years with a mean (SD) of 35.6 (12.7) years (Table 1).

Five of the patients included were manual laborers

(35.7 %). The other occupations encountered included

two office workers, two mechanics, one student, one

security guard, one technician and one sales girl. The

injury happened while hammering metal in 42.9 % of

the patients, and while cutting grass using powered

metal blade tools in an equal number. The only child in

the study was injured by a firecracker explosion, while

the only female was injured in a road traffic accident.

All the patients included were injured in one eye only,

and none of them were wearing protective glasses at

the time of the incident.

The time from injury to surgery ranged between 6 h

and 42 days with a mean (SD) of 5.8 (10.8) days

(Fig. 1). Five of the patients (35.7 %) were operated

within 24 h, three were operated between 24 and 48 h

(21.3 %) and 4 (28.6 %) within 1 week. One patient

was operated after 11 days and another patient after

42 days. The patient with the 42 day delay was a

foreign worker who obtained the injury while ham-

mering metal. He had a 1 mm metallic foreign

embedded in the peripheral part of his lens with

slowly progressive cataract. His vision at presentation,

42 days after the injury, was 6/21 with no intraocular

inflammation or infection. The relatively good vision

in his injured eye was the reason for his late

presentation to the hospital. The time from injury to

surgery did not significantly correlate with the final

visual acuity (p = 0.14).

The IOFB was located in the lens in five patients

(35.7 %), the peripheral retina in five patients

(35.7 %), the vitreous in two patients (14.3 %) and

the macula in two patients (14.3 %). Patients with

anteriorly located IOFBs had significantly better final

visual acuity compared to those with posteriorly

located IOFBs. The more posterior the IOFB the

worse the final visual outcome (p = 0.05).

The IOFB size ranged from 1 9 1 mm (metal) to

8 9 3 mm (plastic). Patients with larger IOFB had

significantly higher risk of developing endophthalmitis

(p \ 0.001). The composition of the IOFB was metal-

lic in 12 patients (85.7 %), glass in one (7.1 %) and

plastic in one (7.1 %). In 13 patients (92.9 %), there

was only one IOFB. Only one case, of road traffic

accident, was found to have three glass IOFBs intra-

operatively.

The majority of patients presented with a visual

acuity less than counting fingers close to face

(71.4 %), with only four patients (28.6 %) presenting

with a visual acuity C6/60. The final visual outcome,

however, was C6/60 in 8 patients (57.1 %), five of

those achieved a postoperative final BCVA of C6/12.

Only 4 patients (28.6 %) ended up with NPL vision as

seen in Table 1. A good initial visual acuity signifi-

cantly correlated with a good final visual outcome

(p = 0.005) (Fig. 2).

Out of the 14 patients included in this study, seven

had a final visual acuity of 6/18 or better (Fig. 3).

Causes of poor visual outcome (vision less than 6/60)

were RD with PVR in three patients (21.3 %) and

endophthalmitis in three patients (21.3 %). One

patient had severe scleral rupture with extrusion of

uvea, retina and vitreous and multiple glass IOFBs.

The injured eye sustained a large scleral laceration

wound with extrusion of the uvea, retina and vitreous.

Primary repair done, but she ended up with ‘NPL’

vision in that eye. She then developed sympathetic

ophthalmia in the other eye, which was treated initially

with oral Prednisolone acetate 1 mg/kg daily and oral

Azathioprine 50 mg daily dose. Enucleation of the

blind eye was done, after discussing with the patient,

to remove the incitement and to assist on recovery of

vision in the other eye. Vision in the only eye was

successfully recovered from 3/60 to 6/9 in 6 weeks’

time.

Int Ophthalmol (2013) 33:277–284 279

123

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280 Int Ophthalmol (2013) 33:277–284

123

Three eyes had endophthalmitis. Two of which had

evidence of clinical endophthalmitis at the time of

initial evaluation, while one developed clinical

endophthalmitis after removal of the IOFB. Only

one patient had a positive growth of Staphylococcus

aureus. The other two patients were culture negative.

A second surgery was needed in six patients—three

were for secondary intraocular lens implantation, one

required evisceration to treat Endophthalmitis, and

one needed Enucleation of the injured blind eye as part

of the treatment of sympathetic ophthalmia in the

other eye. Examples of other cases who ended with

poor final outcome are presented below:

Case 1 A 46 year old male manual laborer sustained

a penetrating injury to his left eye while cutting grass

with a mechanical grass cutter with metal blades. On

presentation, the vision in the left eye was only

perception of light. There was a 8 mm curvilinear

corneal lacerated wound involving visual axis with

hyphaema. Orbital X-ray revealed an intraocular

foreign body. Corneal suturing with anterior chamber

washout with cataract extraction with pars-plana

vitrectomy with IOFB removal with intravitreal anti-

biotic injection was performed on the same day. During

surgery, it was noted that the IOFB had caused a foveal

retinal tear associated with macular subretinal blood

clot. The retinal tear could not be lasered due to the

large volume of subretinal hemorrhage. Subsequently,

he developed corneal scarring and total rhegmatoge-

nous RD with PVR. He refused further surgery due to

the poor visual prognosis. Final vision remained as

perception of light (PL).

Case 2 A 39 year old manual labourer, suffered an

injury to his right eye while hammering metal. There

was a 4 mm corneo-scleral entry would with traumatic

cataract. IOFB was detected by X-rays. During

surgical removal of the IOFB, three retinal tears were

identified and lasered. Silicone oil was used to

tamponade the retina. Intravitreal antibiotics (ceftaz-

idiem and Vancomycin) were used at end of surgery as

per protocol. No organisms were grown in the vitreous

culture. However, he developed postoperative

endophthalmitis which progressed to panophthalmitis

with ‘NPL’ vision. The eye was eviscerated.

Fig. 3 Bar chart showing the initial visual acuity and the final

visual outcome among the patients included in the studyFig. 1 Box plot showing the distribution of ‘Time from injury

to surgery’ in days among locals and foreigners included in the

study. Note the outliers in each group. The number next to the

outliers indicates the case number

Fig. 2 Linear regression chart showing the significant increase

in the final visual acuity when initial visual acuity increases

Int Ophthalmol (2013) 33:277–284 281

123

Discussion

The area of investigation is the country of Brunei

Darussalam which is a sovereign state located on the

north coast of the island of Borneo in Southeast Asia

with a land area of 2,035 square miles (5,271 sq km).

Brunei’s population is estimated to be 408,786 [9], of

which 76 % live in urban areas [9]. The literacy rate is

92.7 % and the average life expectancy is 76.37 years

[9]. Brunei Darussalam has the second highest Human

Development Index among the Southeast nations after

Singapore and is classified as a developed country

[10].

All Brunei citizens have access to free health care

from the Government-run public hospitals.

There are four main Government District Hospitals

in the country, with one in each of the 4 districts. Raja

Isteri Pengiran Anak Saleha (RIPAS) Hospital, where

this study was done, is the tertiary referral hospital in

the country with 523 beds and is situated in the capital

city of Bandar Seri Begawan. The ophthalmology

department at RIPAS Hospital is fully equipped, and

has various sub-speciality units including a vitreoret-

inal unit. The Flying Medical Services provide

primary eye care services in remote villages with

regular schedules of visits and so every resident of

Brunei Darussalam has quick access to RIPAS hospi-

tal. Therefore all intra-ocular FBs occurring in the

country are managed at this tertiary centre.

Eye protection when partaking in risky activities

(e.g, hammering, mowing the lawn, etc.) has been

strongly recommended as early as 1988 [11]. Metal

lawn trimmers (Fig. 4) were specifically more haz-

ardous compared to nylon line trimmers. Lack of eye

protection was a risk factor identified in previous

studies [12], with at least 22 % of patients with open

globe injuries and 9 % with closed globe injuries

failing to wear eye protection. In spite of that, none of

the injured persons in this study were using any eye

protection at the time of the incident.

In the literature, the reported male: female ratio

among IOFB cases ranges between two and five

[13–15]. This condition predominantly involves males

in the 3rd to 4th decade of life [16]. This male

preponderance is thought to be related to occupational

exposure, participation in dangerous sports and hobbies,

alcohol use and risk-taking behaviour [12, 17–23].

In our study, the male: female ratio was 13:1, with the

incident occurring in outdoor environment in all the

cases. This ratio reflects the males’ dominance of

outdoor work activities, which is related to the country’s

culture. Among our patients, the majority of injuries

occurred in the ‘young adult’ age group (21–50 years).

The only child in our study had an IOFB from a

firecracker, which reinforces the need for educating

parents and children about the hazards of such danger-

ous, yet commonly used, items and the preventive

measures need to be adopted to avoid such devastating

injuries. In the literature, 75 % of the IOFBs have been

reported to lodge in the posterior segment [24]. In our

series we report a lesser percentage (64 %) lodged in the

posterior segment, but a higher percentage of IOFBs

lodged in the lens (36 %).

A good initial visual acuity was reported by several

studies to significantly correlate with a better final

outcome [25–28]. Although three patients in our study

achieved a final outcome of C6/18 from presenting

visual acuity of BHM, our study was no exception,

statistically, to the above reports. Thus, even though a

guarded prognosis should be conveyed to the patient,

the surgeon should exert every possible effort to save

as much vision as possible. Other poor prognostic

factors identified in our study were large size of IOFB,

Fig. 4 Metal-bladed lawn trimmer used by manual workers in

Brunei Darussalam

282 Int Ophthalmol (2013) 33:277–284

123

posterior location of the IOFB, presence of retinal

detachment and/or endophthalmitis at presentation.

Postoperative retinal detachment, endophthalmitis,

and PVR have been reported as late complications of

IOFB [29]. We reported the same as indicators of poor

visual outcome among our cases. Endophthalmitis is

an uncommon but potentially catastrophic complica-

tion of penetrating ocular injury with retained IOFB

[30]. In the literature, the incidence of this devastating

complication was reported range from none to as high

as 13.5 % [24, 28, 30–32]. In our study, the incidence

was relatively high (21 %) with all 3 suffering a final

outcome of NPL. The cause was posteriorly located

IOFB in two cases and IOFB within the lens in one

case. The time from injury to surgery for these three

cases was 20, 10 and 15 h respectively. Compared to

the other IOFBs, these were some of the shortest time

gaps. Hence, the delay of surgery did not increase the

risk of infection in our series (p = 0.144). This finding

is consistent with most of the previous reports [33–35].

In contrast, Erakgun and Egrilmez, reported the time

from trauma to surgery as one of the significant

predictive factors of outcome [36].

In our study, positive cultures were obtained in only

one of the three eyes with clinical signs of endoph-

thalmitis. This is less than previous studies, where the

culture-positive results in traumatic endophthalmitis

varied from 50 to 87 % [30, 37, 38]. A possible reason

for this result is probably that our patients were on

topical as well as systemic antibiotics prior to

obtaining the cultures at the time of IOFB removal.

These patients may otherwise have had less virulent

causative organisms accounting for the reduced rate of

culture-positive growth. The commonest organisms

isolated in post-traumatic endophthalmitis are Staph-

ylococcus species and Bacillus species. Mixed infec-

tions are not uncommon [39]. Staphylococcus aureus

was isolated in our only patient with positive culture

result.

The composition of IOFB had no significant effect

on the development of clinical endophthalmitis.

Location of the IOFB, though, showed high signifi-

cance in relation to final visual outcome, with four out

of five (80 %) patients attaining a final vision more

than or equal to 6/12.

A larger prospective study, however, is needed to

allow multivariate analysis of the prognostic factors

involved in the management of IOFBs.

In Brunei Darussalam, the commonest causes of

IOFBs are hammering metal and cutting grass using

powered grass-cutter with a metal blade.

Whenever possible, discussion of the severity of the

intraocular injury and the guarded visual prognosis in

some cases should take place during the preoperative

counseling process before surgical management is

undertaken.

Aside from visual impairment, eye injury is known

to cause significant morbidity in terms of pain,

psychosocial stress, and economic burden. The results

of our study indicate relatively low rates of eye injury.

However, certain segments of the population continue

to be at high risk (males involved in cutting grass or

hammering), and are those to whom prevention

resources should be directed. These groups need to

be educated on the risk of serious eye trauma and the

importance of preventive eyewear. Wearing safety

eyewear made of light weight polycarbonate with a

high impact rating (‘‘Z87?’’) and side shields when

partaking in risky activities can help avoid these

injuries.

A National Eye Trauma Registry, as exists in other

countries [40], would help to evaluate changes in the

epidemiology of eye trauma over time and provide

population-based data for preventive strategies.

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