Management of Intraocular

Foreign Bodies
D. JACKSON COLEMAN, MD, BIRGITTA C. LUCAS, MD,
MARK J. RONDEAU, STANLEY CHANG, MD

Abstract: Thirty-five consecutive cases of perforating ocular injuries with re-

tained intraocular foreign body (IOFB) are examined in this retrospective study.
Of the 35 cases with injuries, 30 (86%) were due to metallic foreign bodies. Of
these, 25 (83%) involved foreign bodies of ferromagnetic origin. Magnetic
extraction in combination with pars plana vitrectomy (or when possible, mag-
netic extraction alone) was successfully used to remove these foreign bodies.
Even in cases where posterior vitrectomy is indicated, magnetic extraction
allows good control of the foreign body during removal minimizing surgical
trauma and the subsequent postoperative inflammatory response. [Key words:
intraocular foreign body, magnet extraction, perforating injury, vitrectomy.]
Ophthalmology 94:1647-1653, 1987

Intraocular foreign bodies (IOFBs) constitute a large
percentage of all ocular traumas and require the use of
advanced diagnostic and surgical techniques to properly
evaluate and successfully manage them.
Techniques and trends in the management of IOFBs
have been examined in numerous clinical studies. 1- 6 Al-
though the prognosis for some visual recovery is good in
these cases, the complexity of the confluent factors sur-
rounding retained IOFBs, which includes the size, mate-
rial, trajectory, reactivity, and inflammatory response,
degree and type of tissue damage, and length of time
since injury, all conspire to limit our understanding of
what constitutes optimal surgical management in a
given case. Due to the large number of covariate factors
involved, convincing statistical evidence concerning
issues, such as the timing of surgery, will only come
from the prospective examination of large cohorts of
trauma patients. These large study populations are
greater than any one ophthalmologist is capable of ac-
cumulating. The value of pooling data through a coop-
erative study such as the National Eye Trauma System
(NETS) thus becomes evident.
In this report, 35 consecutive cases of retained IOFBs
seen by two of us (DJC and SC) during the past few years
were examined. Descriptive clinical statistics including
IOFB type, location, and pre- and postoperative visual
acuity were compared with that seen in recent similar
studies. Areas were identified where further studies and
data would be particularly helpful in clinical manage-
ment and specific trends in patient management are
discussed. An area which seemed particularly worthy of
examination is the specific technique for IOFB removal
which should be used when surgical repair necessitates
posterior vitrectomy and endocoagulation. In such
cases, forceps removal of a magnetic metallic IOFB has
been suggested as a substitute for magnet removal. What
are the advantages and disadvantages of each technique?
The principles that guide surgical removal of IOFBs
and repair of the traumatized eye are (l) to carefully
control extraction and (2) to minimize surgically in-
duced trauma. Adherence to these principles should re-
duce postsurgical inflammation as well as the chance of
intraocular hemorrhage during the procedure. Toward
this end, we prefer to use magnetic extraction where
possible because it allows reduced intraocular manipula-
tion and the alignment of the ferromagnetic IOFB along
the long axis which will minimize the size of the removal
wound site.

From the Department of Ophthalmology, New York Hospital-Cornell Uni-

versity Medical Center, New York.
Presented in part at the American Academy of Ophthalmology Annual
Meeting, New Orleans, November 1986.
Reprint requests to D. Jackson Coleman, MD, Cornell University Medical
College, 1300 York Avenue, New York, NY 10021.
MATERIALS AND METHODS
Patients presenting with ocular trauma were exam-
ined for the presence of retained IOFB using, where
applicable, indirect ophthalmoscopy, x-ray, computed

1647
 OPHTHALMOLOGY • DECEMBER 1987
I. 0. F. B.
SITE OF PERFORATION
Fig I. Schematic presentation of perforation sites of IOFBs in our
series of 35 patients approximated with preliminary NETS data.
25%
40%
vitreous
hemorrhage
Vitreous loss }
Uveal prolapse ZB%
Inflammation 19%
Fig 2. Schematic presentation of the immediate complications of per-
forating injuries with IOFB seen in our series of 35 patients approxi-
mated with preliminary NETS data.
tomography (CT), and immersion or contact ultraso-
nography. Localization of IOFBs was most often ac-
complished with CT. Reformatted CT can provide ex-
cellent localization of a radiodense IOFB with relation
to the globe outline. Ultrasound was used to examine
the relationship ofiOFBs to soft tissue pathology such as
retinal detachment and has been shown to be particu-
larly useful in surgical treatment planning where vitre-
ous hemorrhage exists secondary to traumatic injury.
Intraoperative Roper-Hall localization and an ultra-
sound magnet test were used to determine the magnetic
properties of the IOFB.
1648
• VOLUME 94 • NUMBER 12
In 22 cases, a pars plana vitrectomy was used to free
the IOFB from adhesions and to clear a path for mag-
netic extraction. Where possible, early vitrectomy and
IOFB removal ( <72 hours) were performed.
Typically, magnetic IOFBs were removed with the
electromagnetic intraocular tip using a transvitreal ap-
proach through the irrigation/light or suction/cutter
surgical wounds. The use of a single irrigation/light port
reduces the number of wounds and more importantly
allows the surgeon to gauge the position of the infusion
port so as to insure that it is in the vitreous cavity in
cases where hemorrhages can make visualization of a
separate infusion tip impossible. 7 In four cases with large
IOFBs, removal was accomplished through the original
wound site. This is the procedure of choice in cases of
large IOFBs that are seen relatively soon after injury. In
these cases, primary wound closure is performed ini-
tially, which allows standard pars plana vitrectomy in
the reformed globe. After vitrectomy, the original
wound site can be opened, and the intraocular magnetic
tip is used to remove the IOFB. This technique has the
advantage of alleviating the need for enlarging surgical
wound sites but is best performed on fresh wounds.
Nonmagnetic IOFBs were removed with the foreign
body forceps (Grieshaber, Langhorne, PA) and Wilson
vitreous foreign body forceps (Storz, St Louis, MO).
Where applicable, additional procedures including pars
plana lensectomy, scleral buckling procedures, endo-
photo- and endocryocoagulation, cryopexy, and per-
fluorocarbon gas retinal tamponade were used in surgi-
cal repair of the traumatized globe.
RESULTS
Of the 35 cases ofiOFBs in our series, 30 (86%) of the
injuries were due to metallic IOFBs, the remaining 5
(14%) consisted ofthree glass and two concrete particles.
Twenty-two (63%) were caused by the use of a hammer
on a chisel or metal, three (8.5%) were caused by BB
guns, and ten (29%) were caused by various other mech-
anisms most commonly connected with the use of ma-
chine tools. Twenty-five of the 30 metallic IOFBs
proved to be magnetic and were all extracted intraopera-
tively by the use of ophthalmic magnets. This represents
a total of magnetic IOFBs of 71% of all IOFBs and 83%
of all metallic IOFBs. The sites of perforations for for-
eign bodies in our series are shown schematically in Fig-
ure I.
The immediate complications of the perforation and
the IOFB are shown in Figure 2. Immediate damage
occurred most frequently to the lens, 16 of the 35 (46%)
cases. Retinal tears and/or detachment were seen in 13
(37%) eyes, encapsulation of the IOFB was present in 13
(37%) patients and severe or moderately severe vitreous
hemorrhage in 12 (34%). Other less-frequent complica-
tions included vitreous membrane formation (4, 11% ),
tears of the iris ( 1, 3% ), hypopyon ( 1, 3% ), and siderosis
bulbi (I, 3% ). The last case was a patient transferred for
secondary IOFB extraction 1 year after injury. All 35
 COLEMAN et al • INTRAOCULAR FOREIGN BODIES

NLP

LP i *
p
HM *
0
s CF
t *
*
0
p 20/400
e
r
a 20/300 *
t
i
v
e
20/200 * * * *
Fig 3. Scattergram of visual
acuities pre- and postopera- v 20/100 *
i
tively in our series of 33 pa- s
tients. u 20/80 *
a
1
20/60 *
a
c
u 20/40 *
i
t
y 20/30 *
20/25
* *
20/20 t *

20 20 20 20 20 20 20 ?._0 ~ 20 CF HM LP NLP
20 25 30 40 60 80 100 200 300 400
pre-operative visual acuity

foreign bodies were removed at initial surgery at this
institution, and vitrectomy was performed in 22 cases.
Figure 3 is a scattergram of the pre- and postoperative
vision. Twenty-seven cases (82%) retained or improved
their visual acuity postoperatively. For further analysis,
postoperative visual acuities were grouped into three
domains. Good visual outcome was one resulting in a
vision better or equal to 20/40. Vision was considered
useful between 20/40 and 20/300, and unsuccessful vi-
sual rehabilitation was one of less than 20/300. Two of
the 35 patients were subsequently lost to follow-up, and
a postoperative visual acuity is not reported. Of the re-
maining 33 cases, 21 (64%) retained at least useful vi-
sion. Twelve (36%) resulted in good visual acuity of
20/40 or better, 9 (27%) retained "working" vision
(20/40-20/300), and 12 (30%) obtained less than 20/300
final vision.
Preoperatively, only seven (21%) patients presented
with a vision of 20/40 or better, and six ofthese retained
good vision of 20/40 or better postoperatively. Only one
of the seven patients had a reduction in visual acuity
from a borderline 20/40 to 20/80 after operation. Of the
24 (73%) cases with less than 20/300 vision before oper-
ation, only five proceeded to a visual acuity of 20/40 or
better afterward, whereas 12 remained in the unsatisfac-
tory group. Seven of these 12 resulted in light perception
only. These data support the axiom that a good preoper-
ative visual acuity is one of the most important prog-
nostic factors for visual rehabilitation.
Overall improvement of visual acuity of one line or
better occurred in 20 (61%) patients, further deteriora-
tion of one line or more occurred in 6 ( 18% ). This loss of
vision was mostly related to chronic or irreparable, sec-
ondary retinal detachment. In four cases, visual deterio-
ration occurred or progressed over time, again due to
secondary retinal detachments in three cases. One of
these went on to phthisis. Only 1 of the 35 eyes has
required enucleation. This was one of the three cases
presenting with no light perception on admission di-
rectly after the injury.
In our series of 30 cases with metallic foreign bodies,
there was no correlation between the material of the
foreign body and the visual prognosis. This may be due
to the small number of cases-only five with nonmag-
netic metallic IOFBs.
The importance of primary vitreous hemorrhage for
the later prognosis has been reported previously and is
suggested in our series. 8•9 Despite the limited number of
cases, we found that in the 12 cases with severe or mod-
erate vitreous hemorrhage caused by the injury, 5 did

1649
 OPHTHALMOLOGY • DECEMBER 1987
Fig 4. Typical aspect of small metallic IOFB "knapping" showing the
sharp edges.
Fig 5. Schematic presentation of the locations of IOFBs as derived
from a preliminary NETS data review.
not regain useful vision at all (light perception or no
light perception) and only 4 achieved a visual acuity of
20/40 or better.
DISCUSSION
The overall incidence of perforating ocular injuries
appears to be declining due to greater awareness and the
use of protective measures. 10 Nevertheless, these injuries
often present a considerable difficulty in management,
particularly when retained IOFBs are present. The ad-
vent of endovitreal microsurgery offers a spectrum of
treatment possibilities for the severely injured eye as
well as for the removal of IOFBs. The extensive arma-
mentarium of surgical techniques often presents a sur-
feit of choices for the appropriate approach in each case.
1650
• VOLUME 94 • NUMBER 12
Of all ocular perforations, IOFBs occur in about
40%. 11 De Juan et al 8 who reported a series of 453 cases
seen at the Wilmer Institute, found ocular perforations
to be caused by: projectile (41 %); lacerations (37%); and
blunt force (22%).
The variety of foreign bodies is of course nearly infi-
nite, but in our series, 71% were caused by magnetic
metals approximately similar to the 80 to 90% reported
by other investigators. 9 - 11
The causative agent for IOFBs as reported by Perci-
val10 and Cridland 12 were hammer on metal in approxi-
mately 60% of cases, 25% were caused by machine tools,
and 15% by weapons or other miscellaneous objects. In
our series, 22 of the 35 (63%) cases were caused by the
hammer-on-metal mechanism, and 3 (8.5%) were due to
BBs. The high compressive and concussive forces seen
in BB injuries are usually regarded as the reason for the
poor prognosis in these cases. Several cases with BBs as
the causative agent had to be excluded from this study
because they caused through-and-through perforations,
thus no longer constituting IOFBs.
The locations of foreign bodies (when metallic) gener-
ally are in the posterior segment due to the density and
high velocity of small metal fragments. In our series, all
of the metallic IOFBs penetrated to the posterior seg-
ment. These fragments most commonly resemble min-
iature knappings of stone-age implements (Fig 4) and
thus may cut cleanly into the eye with a minimum of
concussive trauma. Potts and Distler 13 published similar
results of experimental studies on the shape and veloci-
ties of IOFBs. If critical corneal or retinal elements are
spared, the visual outcome may be quite good as com-
pared with larger and/or more concussive fragments. 14 •15
In Figure 5 the locations of foreign bodies are shown
schematically as derived from a preliminary NETS data
review.
Once the presence of an IOFB has been established,
the principles of any surgical attempt for removal are to
( 1) carefully control extraction and (2) minimize surgi-
cally induced trauma. Because up to 90% of IOFBs are
magnetic, the use of magnets has long been advocated
for their removal. The principles of magnetism have
been well reviewed by Lancaster, 16 Duke-Elder, 17 and
McCaslin, 18 among others.
Since foreign-body extraction is currently performed
usually in conjunction with posterior vitrectomy and
endocoagulation, instrument removal may be substi-
tuted for the use of a magnet. With nonmagnetic foreign
bodies, it is indeed unavoidable. We prefer magnetic
extraction whenever possible, primarily because it
allows for reduced intraocular manipulation and the
ability to minimize the removal wound size due to the
longitudinal alignment of the IOFB (Fig 6). The chan-
ces of intraocular bleeding from the entry wound site
can be further minimized by use of an intraocular mag-
netic tip. 19 •20
The magnets used in ophthalmic surgery are of two
general types: electromagnets and rare earth magnets.
Most permanent rare earth magnets require a large
magnet volume to provide sufficient force to move a
 COLEMAN et al
Fig 6. Left, steel nail in gelatin before magnetic attraction. Right, immediate alignment of the nail along its long axis (minimizing cross-sectional
diameter) upon magnetic induction.
foreign body or lift it up over a very short distance. The
large size magnet needed for such tasks limits the use of
rare earth magnets to cases where they are used as hand
magnets for contact extraction of IOFBs. Their most
frequent application is for foreign bodies in the anterior
chamber or wherever the magnet can be introduced to
touch the foreign body and then lead it out of the wound
under complete control. The stronger rare earth intraoc-
ular magnet of Parel21 represents a new type of magnet
designed for the vitreosurgical approach. Its magnetic
pole, concentrated at the tip of the instrument, mini-
mizes the risks of accidents due to misalignment. Rare
earth magnets, however, lose up to 15% of their pulling
power per year and should be checked at regular inter-
vals. More powerful magnets are required for larger
IOFBs or ones that have to be lifted up or pulled across
an interspace. Electromagnets are more sl.titable in this
situation. Electromagnets are made o'f an iron core
placed inside a coil of wire. Magnetism is induced in the
iron core when a current is sent through the coil. Elec-
tromagnets can be hand held with different tips for in-
traocular use or in the form of giant magnets and inner
pole magnets for extraocular use. The main disadvan-
tage of electromagnets, apart from their relative bulk, is
• INTRAOCULAR FOREIGN BODIES
due to incorrect use or inadequate preoperative foreign
body localization. Incorrect alignment of the electro-
magnet with the IOFB may lead to incarceration of the
foreign body in the lens or retina or to retinal defects
caused by inadvertently pulling the foreign body across
delicate ocular structures. It is for this reason that an
understanding of the basic principles of magnetism and
of each specific magnet is of great importance in their
application.
Magnetic force applied to a body in a magnetic field is
related to ( 1) the strength of the magnetic field at that
point and (2) the magnetic field gradient. The strength is
dependent on the density of magnetic field lines flowing
through a given point. The strength of a magnetic field
decreases by the square of the distance as described in
Coulomb's law (H = mm'/d 2 where m and m' describe
the strength of two poles and d 2 the distance between the
poles). The magnetic fi.eld gradient also decreases in
proportion to the distance from the magnet. It is for this
reason that all magnetic foreign bodies align themselves
with their long axis along the field gradient. This is par-
ticularly valuable when teasing a foreign body out of the
eye through the smallest possible incision to cause the
least damage to surrounding tissue as the lesser girth is
1651
 OPHTHALMOLOGY • DECEMBER 1987
perpendicular to the field of the magnet. The material of
an IOFB is of paramount importance to the question of
induction of magnetism in the foreign body.
Lancaster 16 defined a good ophthalmic magnet as one
with a pulling power sufficient to pull a 1-mm steel ball
over a distance of 2 em with a force 5000 times its
weight. We find it easy to perform this test by using steel
(copper coated) BBs to demonstrate and roughly quan-
tify the lifting power of a magnet. Rare earth magnets
typically lift about four BBs of 330 mg each, electro-
magnets lift 12 to 14 of these BBs. Clearly, electromag-
nets are more powerful, but the small size of the tips of
rare earth magnets often provide an advantage in guid-
ing small fragments out through a small incision. The
development of new superconducting magnets should
offer us even better efficiency in the future.
De Juan et al 8 •15 have defined the following seven
parameters of prime importance to the final visual out-
come and prognosis after perforating ocular injuries8 •15 :
( 1) initial visual acuity after the injury; (2) presence of an
afferent pupillary defect; (3) type of injury; (4) location
and extent of the penetrating wound; (5) type of lens
damage; (6) presence and severity of vitreous hemor-
rhage; and (7) type of IOFB. The variety and scope of
these variables emphasize the difficulty in predicting
prognosis. Nevertheless, perforating injuries caused by
foreign bodies usually have a better prognosis than those
after blunt trauma. In the first group, perforations with
metallic foreign bodies tend to fare better. This is ex-
plained by the high energy, smaller size, and sharpness
of metallic foreign bodies causing less gross damage than
larger blunter objects. Different shapes and sizes of for-
eign bodies have been explored experimentally by Potts
and Distler, 13 confirming that knife-shaped metal
splinters or knappings, as produced by machine tools or
hammer and chisel, need the least energy to penetrate
into the globe.
On analysis of their results, Neubauer 14 found that the
prognosis for a nonmagnetic foreign body, being larger
and more blunt in general than the others was consider-
ably worse. Fifty percent of these patients obtained a
final visual acuity of 20/200. The relationship of visual
outcome to size of IOFB was expressed as 85% with
relatively good vision with a foreign body smaller than 2
mm 2 , as opposed to only 15% good vision for those
foreign bodies greater than 10 mm 2• In scleral perfora-
tion, more penetrating force remains because the iris
and lens do not absorb the energy, as in corneal perfora-
tions. This explains why the majority of double perfora-
tions and severely damaged eyes is found with scleral
perforations. 14
A detailed comparison of postoperative visual acuity
in our series with that seen in other comparable studies
is complicated by a number of factors. The foremost of
these difficulties is the difference in the method of re-
porting visual acuity in the various studies. Cases are
grouped in different ways and different measurement
systems are used. The other major factor complicating
comparative anaylsis of visual acuity data is the covar-
1652
• VOLUME 94 • NUMBER 12
iate effect that clinical variables have on final visual
outcome. These variables cannot be corrected for when
comparing and contrasting acuity outcome. In our
series, all foreign bodies penetrated into the posterior
portion of the globe. In other reported series, cases of
anterior IOFBs and scleral foreign bodies are included in
the overall visual results. In these studies, the visual ac-
uity after removal of the foreign body was greater or
equal to 20/50 in 77 to 85%. In our series, 39% had
postoperative visual acuities of at least 20/50. The only
common subgroup of patients with a similar IOFB loca-
tion comes from Percival's 10 data in which cases of vitre-
ous IOFB resulted in a visual acuity of at least 6/12 after
surgery in approximately 50%.
Several questions remain that can only be more effec-
tively answered with a large series. These questions re-
late to the extent of surgery, for example, vitrectomy
with lens removal and scleral buckle and to the timing of
such surgery. Currently, no single series provides
enough cases to definitively answer these questions. The
NETS offers us an opportunity to provide better answers
to these questions.
Our own preference for early surgery (< 72 hours) is
based on the concept of attempting to reduce inflam-
mation by early removal of inciting agents, whether for-
eign material, blood, or lens fragments. 22 The random
nature of severity of injury, however, combined with the
many variations in surgical approach will require a con-
siderable number of cases before this and similar ques-
tions can, hopefully, be answered unambiguously.
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