Avoid delaying vitrectomy by foregoing diagnostic testing if the intraocular foreign body is visible and endophthalmitis is incipient.

Abstract

Intraocular foreign bodies (IOFBs) are known to cause endophthalmitis at a high rate. Media opacity (corneal edema, cataract, vitreous hemorrhage) and the need for diagnostic testing often prevent timely recognition of an infection; the resulting treatment delay worsens the prognosis. We present a case in which direct visualization of a posterior-segment IOFB and the incipient endophthalmitis allowed foregoing further testing (computed tomography), shortening the time to sight-saving vitrectomy. A 16-year-old male presented 19 h after a hammering-related injury. The media remained clear, permitting recognition of a large area of purulent retinal infiltrate adjacent to the intravitreal IOFB. Within one hour the patient underwent comprehensive surgery (wound closure, vitrectomy, IOFB removal, and intravitreal antibiotic injection). The development of full-blown endophthalmitis was prevented, even though the vitreous culture yielded Staphylococcus epidermidis. Final visual acuity at one year was 20/30, with the retinal injury approaching to within 1 mm of the fovea. In opaque-media eyes with a suspected IOFB treatment delay is common, due to waiting for computed tomography (CT) - instead of ultrasonography, which can safely identify the IOFB in over 90% of cases. Expediting surgery is the best prophylaxis against post-presentation endophthalmitis. Our case highlights the benefits of early vitrectomy based on direct inspection of the IOFB alone; instant ultrasonography instead of a CT-caused delay may save eyes with infection developing behind media opacity.