We read with interest the article on ‘Predictive factors and outcomes of posterior segment intraocular foreign bodies’ by Choovuthayakorn et al.1
In the results section, 4 (4.76%) of the 84 eyes with intraocular foreign bodies (IOFB) underwent primary enucleation. Given the trend to avoid primary enucleation following trauma, it would have been helpful if the authors had described the indications for primary enucleation in these eyes and why enucleation was preferred over evisceration.
One of the key conclusions drawn, and perhaps the most controversial, is that good outcome can be achieved even if there is delay in removal of IOFB. The incidence of endophthalmitis reported by the authors in this series was 9.1% that, though comparable with the literature, was still quite high. In another case series of 1421 eyes with IOFB by Zhang et al,2 the reported rate of endophthalmitis was much higher at 16.76%, pointing possibly to the influence of IOFB presence. The two referenced papers3, 4 citing low-risk or no risk of endophthalmitis with delayed removal of IOFB were in the context of war injuries, whereby high-velocity explosives and the heat generated before impact could potentially partially account for the relatively lower incidence of endophthalmitis. Furthermore, there was no mention about the use of intravitreal antibiotics in this case series, which has a major role in prevention and treatment of post traumatic endophthalmitis.5
In conclusion, we are concerned that the article may create the impression that delayed removal of IOFB can achieve good visual outcome by giving systemic antibiotics and prompt primary repair. On the contrary, especially if there is presence of a vegetative foreign body, prompt wound closure with simultaneous removal of IOFB with systemic and intravitreal antibiotics should be the preferred practice pattern for most ophthalmologists.5 Second sitting removal of IOFB should be considered only in patients with significantly large corneoscleral wounds that may leak during vitrectomy and in cases with associated retinal detachment requiring complex vitreoretinal surgery.5
Choovuthayakorn J, L Hansapinyo L, Ittipunkul N, Patikulsila D, Kunavisarut P . Predictive factors and outcomes of posterior segment intraocular foreign bodies. Eye 2011; 25: 1622–1626.
Zhang Y, Zhang M, Jiang C, Qiu HY . Intraocular foreign bodies in china: clinical characteristics, prognostic factors, and visual outcomes in 1,421 eyes. Am J Ophthalmol 2011; 152 (1): 66.e1–73.e1.
Thach A, Ward T, Dick JN, Bauman WC, Madigan Jr WP, Goff MJ et al. Intraocular foreign body injuries during operation Iraqi freedom. Ophthalmology 2005; 112 (10): 1829–1833.
Colyer M, Weber E, Weichel E, Dick JS, Bower KS, Ward TP et al. Delayed intraocular foreign body removal without endophthalmitis during Operations Iraqi Freedom and Enduring Freedom. Ophthalmology 2007; 114 (8): 1439–1447.
Yeh S, Colyer MH, Weichel ED . Current trends in the management of intraocular foreign bodies. Curr Opin Ophthalmol 2008; 19: 225–233.
The authors declare no conflict of interest.
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Agrawal, R., Laude, A. Predictive factors and outcomes for posterior segment intraocular foreign bodies. Eye 26, 751–752 (2012). https://doi.org/10.1038/eye.2012.24