CASE REPORT

Intraocular foreign body during cataract surgery

Thompson, Alexander MS; Osher, Robert H. MD; Werner, Liliana MD, PhD; Park, Sally MD; Wilkinson, Samuel MD

Author Information
doi: 10.1097/j.jcro.0000000000000088
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Abstract

The presence of intraocular foreign bodies during cataract surgery has been a topic of concern among ophthalmologists for decades.1 Previously published reports demonstrate foreign bodies embedded in the iris, in the cornea, and often in the incision sites that are easily visible through the operating microscope and during the slitlamp examination. Given their reflective nature, they have generally been attributed to instruments used during phacoemulsification, and analysis of recovered particles has typically confirmed this etiology.2,3 However, recent studies have proposed other substances as the source of these reflective particles, such as silicone used in manufacturing disposable blades.4 Other unwanted foreign material such as lint has also been commonly seen, and a new technology has been developed to purify the sterile field.5 Therefore, it is important to keep an open mind about the origin of these particles and methods by which they may be introduced into the eye.

We present a video-documented case in which a foreign body derived from the spike used to pierce the balanced salt solution bag was introduced into the eye during phacoemulsification.

Patient Consent Statement

The surgical case and video contain no personal identification information and did not require review by an IRB; thus, signed consent was not obtained.

CASE REPORT

A 70-year-old woman was scheduled for routine cataract extraction with implantation of a posterior chamber intraocular lens. During the phacoemulsification, a white fleck about 1 mm in diameter was observed traveling through the infusion line into the eye (Video 1, https://links.lww.com/JC9/A367). The surgeon immediately recovered the foreign body with forceps through the main incision. The remainder of the operation proceeded uneventfully. There was no injury to the eye by the fragment, and no remnants of the fragment were identified postoperatively. The fragment that broke into 3 pieces was preserved and sent for analysis.

The first specimen was the white foreign body that entered the anterior chamber through the infusion line during phacoemulsification. It was sent inside of a plastic vial containing the balanced salt solution. It was removed from the vial and placed on a glass slide for gross analysis, and photographs taken with a camera coupled to a gross microscope (AmScope MU1000-HS). It was then allowed to dry at room temperature for 72 hours. Its surface and composition were characterized by scanning electron microscopy (SEM) coupled with energy-dispersive x-ray spectroscopy (EDS). The specimen was mounted on an aluminum support stub using a double-sided carbon tape and analyzed under a low vacuum mode, which does not require prior coating with gold or carbon. The support containing the specimen was loaded into the SEM (Teneo, Thermo Fisher Scientific) for analyses under relatively high water vapor pressure (0.23 to 0.38 torr), at room temperature, and an accelerating voltage of 10 kV. Three different regions of the surface of the specimen had their elemental composition assessed through the EDS.

The second specimen (control) was a large piece of white material in a conic shape, measuring 9.0 mm in its largest dimension, representing the spike used in the balanced salt solution bag. A small slice/fragment was cut from it with a razor blade. It was immersed in the balanced salt solution for 20 minutes and then prepared for imaging as described above, after drying at room temperature for 72 hours.

RESULTS

The first specimen was found to be broken into 3 fragments inside of the submitting vial. Each fragment had the morphological appearance of white plaques of irregular size and shape under gross inspection (Figure 1, A). Under SEM, each plaque exhibited 3 regions: a dark gray area that appeared to correspond to the baseline material, as well as light gray and white areas that appeared to correspond to deposits on the surface of the baseline material (Figure 1, B). Under high magnification, the surface of the dark gray area was observed to be irregular, with some porosity (Figure 2, top). EDS of this area showed that the main composition was carbon and oxygen, indicating that the material was organic, most likely a polymer. Elemental analysis of the light gray area showed peaks of carbon, oxygen, and sodium, whereas the elemental composition of the white areas was basically sodium and chlorine, indicative of salt deposits (Figure 2, bottom).

F1
Figure 1.:
A: Gross photograph showing the fragments of the white foreign body. B: Scanning electron photomicrograph showing one of the fragments of the foreign body.
F2
Figure 2.:
Scanning electron photomicrograph (top) and energy-dispersive x-ray spectrum (bottom) obtained at the dark region of the foreign body, corresponding to its baseline material. The composition is basically of carbon (C) and oxygen (O).

Regarding the slice/fragment of the control specimen, its morphological appearance was similar to that of the first specimen (Figure 3, A and B). The main composition of the baseline material was also carbon and oxygen. Salt deposits composed of sodium and chlorine were also observed on the surface of this fragment. The main difference was the presence of some deposits rich in silicon, which may correspond to contamination with a silicone compound (Figure 4). It is therefore likely that the foreign body that entered the anterior chamber through the infusion corresponds to a fragment of the spike used in the balanced salt solution bag.

F3
Figure 3.:
A: Gross photograph showing the spike used in the balanced salt solution bag. B: Scanning electron photomicrograph showing the fragment cut out of the spike with a razor blade.
F4
Figure 4.:
Energy-dispersive x-ray spectrum obtained at the dark region of the fragment shown in figure 2, corresponding to its baseline material. The composition is basically of carbon (C) and oxygen (O). A small peak of silicon may correspond to contamination with a silicone compound.

DISCUSSION

In this study, a new mechanism of intraocular foreign body deposition was reported, in which a fragment of the spike used in the balanced salt solution bag broke free and was directly visualized entering the eye through the irrigation sleeve. The piece was retrieved, and analysis showed that its elemental composition matched that of the spike, along with deposits of a residual balanced salt solution adherent to both specimens.

Several hypotheses could explain how the spike fragment sunk inside the irrigation bag and subsequently entered the irrigation line reaching the anterior chamber. It is possible that the spike was damaged when it pierced the bag. It is also possible that the integrity of the spike was compromised during the manufacturing or packaging process, leaving it vulnerable to fragmentation.

Studies have identified intraocular particles of unique composition deposited during cataract removal, although they have generally been metallic and derived from surgical instrumentation.2,3,6–8 More recently, there has been speculation over new sources of foreign bodies that may be deposited in the eye. Some authors have proposed different residues on surgical equipment as potential contaminants, including ophthalmic viscosurgical device material, balanced salt solution, and mineral deposits from autoclaving.9 A recent report proposed that silicone particles used in the manufacturing of single-use blades can be deposited in incision sites.4 Of interest, the EDS analysis presented here revealed deposits of silicone on the control specimen. It is possible that the spike, container, or balanced salt solution itself is a source of silicone contaminants in addition to those previously described, including possible contamination with silicone oil from the disposable razor blade used to section the control material for analysis (spike). This may warrant investigation because there has been speculation over intraocular deposition of silicone into the intraocular space by several authors.9,10

Unlike those associated with traumatic injury, the introduction of foreign bodies during cataract surgery has not been associated with adverse outcomes over time.6,11 Nonetheless, reporting these incidents is necessary to increase the awareness of new, potential sources of intraocular contamination, push industry toward better manufacturing practices, and ultimately minimize the risk of potentially unidentified adverse effects. Moreover, continued study of these fragments, their composition, and their suspected origin moves the field toward the ideal operation, in which the only foreign body remaining in the eye after cataract removal is solely the device placed with intention, the intraocular lens.

WHAT WAS KNOWN

  • Intraocular foreign bodies have been observed in the eye during phacoemulsification.

WHAT THIS PAPER ADDS

  • This is the first report, to our knowledge, in which the foreign body was likely derived from the spike used in the balanced salt solution bag.

Acknowledgments

The authors thank Paulo J. Perez, PhD, from the Utah Nanofab, University of Utah, who assisted with surface analysis.

REFERENCES

1. Dunbar CM, Goble RR, Gregory DW, Church WC. Intraocular deposition of metallic fragments during phacoemulsification: possible causes and effects. Eye (Lond) 1995;9:434–436
2. Braunstein RE, Cotliar AM, Wirostko BM, Gorman BD. Intraocular metallic-appearing foreign bodies after phacoemulsification. J Cataract Refract Surg 1996;22:1247–1250
3. Davis PL, Mastel D. Anterior chamber metal fragments after phacoemulsification surgery. J Cataract Refract Surg 1998;24:810–813
4. Raevis J, Astafurov K, Wilson B, Laudi J. Post-cataract surgery hyperreflective lesions within corneal incisions suspected to be silicone oil from disposable blades. J Cataract Refract Surg 2020;46:975–978
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9. Osher RH, Masket S, Lichtenstein SB, Steinert RF, Koch DD. Reflective particles in the cataract incision. Cataract & Refractive Surgery Today. 2005. Available at: https://crstoday.com/articles/2005-sep/crst1005_05-php-2/. Accessed May 21, 2022.
10. Osher RH. Comment on: post-cataract surgery hyperreflective lesions within corneal incisions suspected to be silicone oil from disposable blades. J Cataract Refract Surg 2021;47:281–282
11. Sneed SR, Weingeist TA. Management of siderosis bulbi due to a retained iron containing intraocular foreign body. Ophthalmology 1990;97:375–379

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