Figure 1. Foreign body under the temporal conjunctiva of the patient’s left eye
Dr Leonid Skorin Jr
OD DO MS FAAO FAOCO
Department of Ophthalmology, Mayo Clinic Health System, Albert Lea, Minnesota
Steven A Turpin MS
Pacific University College of Optometry Forest Grove, Oregon
Complications associated with phacoemulsification cataract surgery have been well documented.
Books dedicated to the subject highlight issues with capsulorrhexis execution, endothelial damage from phacoemulsification, intraocular lens implant malpositioning and so on.1,2 Sections specific to wound construction and closure discuss the advantages of different sutureless incision techniques including clear cornea and scleral tunnelling.
One aspect not addressed is the rare possibility of a foreign body entering the eye through the incision which, by definition, is not closed with sutures. Our case highlights one such situation where the retained foreign body happened to be the patient’s own cilium or eyelash.
Complications involving retained cilia occur very infrequently after cataract surgery. Only a handful of cases has been reported involving cilia found in the anterior chamber of patients following phacoemulsification cataract surgery.3-6 These cilia can be completely inert prompting no treatment or cause severe endophthalmitis requiring immediate surgical removal.
The unique aspect of our patient’s retained cilium was its location. In our case, the cilium was positioned under the temporal conjunctiva in the potential space between the episclera and Tenon’s capsule. As such, we report the first case detailing diagnosis and excision of a subconjunctival cilium after phacoemulsification cataract surgery using the scleral tunnelling incision technique and conjunctival peritomy.
A 77-year-old white female was referred back by her comanaging optometrist to the eye clinic for a conjunctival foreign body removal. The object was identified by her optometrist in the temporal conjunctiva of her left eye.
The patient had complained that her left eye felt dry, irritated and gritty. She reported that the discomfort in her left eye started gradually about one day after she had undergone phacoemulsification cataract surgery in the same eye and it continued to bother her for the following two weeks. She denied any redness, pain, purulent discharge, photophobia or epiphora.
The patient had previously been diagnosed by the referring optometrist with nuclear sclerosis in both eyes and had recently undergone phacoemulsification with intraocular lens implant in both eyes. The left eye was done first and the right eye was done one week later. When she presented to her comanaging optometrist, it had been two weeks since the operation on her left eye. No complications were noted during either procedure or during any of the previous follow-up visits. When she was asked directly about any accidental rubbing of the left eye, the patient emphasised that she had been wearing the prescribed eye shield over her left eye while sleeping for one week following surgery and had not rubbed the eye during the day when the shield was not worn.
The patient presented to our office for consultation about one month after surgery was performed in the left eye. Our patient’s ocular medications included prednisone acetate 1%, instilled three times daily in the right eye and prednisone acetate 1%, instilled once daily in the left eye. There was no history of previous eye injuries or other eye surgeries. The family history was negative for any pertinent ocular conditions.
Systemically, the patient had previously been diagnosed with hepatitis B, depression, anxiety, rheumatoid arthritis, headaches, esophageal reflux, hyperlipidaemia and osteoarthritis of her hips, back and knees. Current oral medications include omeprazole 20 mg twice daily, gabapentin 600 mg three times a daily, trazodone 50 mg once in the evening, citalopram 50 mg once in the evening, lovastatin 20 mg once daily, sumatriptan 100mg as needed, lorazepam 0.5 mg as needed and acetaminophen 1 gram as needed. She is allergic to hydrocodone, macrolide antibiotics and sulfa drugs.
Entering uncorrected distant acuities were 20/20- OD and 20/25 OS. Extraocular motilities were full for both eyes. Pupils were equal, round and reactive to light. Confrontation fields were full with no restrictions in both eyes. The anterior segment examination of the right eye revealed trace cells in the anterior chamber, due to the recent cataract surgery. The cornea, conjunctiva, iris, lids and lashes were all unremarkable in the right eye. The surgical incision was stable and Seidel’s sign was negative. The intraocular lens implant was stable, centred and clear.
In the left eye, all findings were unremarkable except the presence of a slightly curved, tapered, cylindrical, semi-translucent foreign body which was oriented vertically, in the temporal conjunctiva approximately 10 mm from the limbus (Figure 1). The cilia-like foreign body was measured to be 5.0 mm in length and less than 1.0 mm in diameter. Using optical section illumination, it was determined that the foreign body was located between Tenon’s capsule and the episclera. Intraocular pressures were 15 mmHg OD and 17 mmHg OS measured with the iCare tonometer. A dilated fundus examination was not performed.
It was decided to excise the foreign body from beneath the conjunctiva due to the patient’s ocular irritation symptoms. Consent was obtained and the patient was sterilely prepped for removal of the foreign body. Lidocaine hydrochloride ophthalmic gel 3.5% was applied to the temporal conjunctiva of the left eye and allowed to stay in contact with the site for 60 seconds.
The surgical procedure was performed behind the slitlamp. Westcott tenotomy surgical scissors were used to make a small 0.5 mm incision above the upper end of the foreign body. Using jeweller’s forceps, the tip of the foreign body was engaged and it was removed through the small incision. The cilia was not attached to any conjunctival tissue and slid easily through the tunnel that the conjunctival tissue had formed around it. The specimen was placed in a sterile container with 10 per cent formalin and sent to the pathology lab.
Bacitracin ophthalmic ointment was applied to the patient’s left eye. The patient was prescribed the bacitracin ointment for use in the left eye twice daily for one week to provide prophylactic protection against infection of the incision site. The pathology report revealed that the specimen was a fine hair with some pigmentation (Figure 2).
Figure 2. Histopathology of cilia specimen; note the interrupted medullary pigmentation pattern
The mechanism by which the cilium entered the subconjunctival space is still unknown but we suspect the cataract surgical incision site may have provided a point of entry. The scleral tunnelling technique was used in the phacoemulsification surgery in both of the patient’s eyes. To gain entry into the globe using this particular technique, a conjunctival peritomy needs to be performed.
A 3 mm wide conjunctival flap was made using Westcott tenotomy surgical scissors 1 mm posterior to the limbus at the 12 o’clock position in order to expose the sclera. A partial thickness incision was made into the sclera using a crescent knife and the sclera and peripheral cornea were dissected using the same instrument. A keratome was then used to enter the anterior chamber via the dissection channel. This forms a self-sealing incision. Following the surgery, the conjunctival flap was laid back down and allowed to heal without sutures.
Nearly all of these conjunctival flaps are sealed when patients present for their one-week post-operative examination. As a result, we believe that an eyelash entered under the conjunctival flap soon after the cataract surgery. It then must have migrated through the potential space between Tenon’s capsule and the episclera to its position under the temporal conjunctiva.
To our knowledge, this is only the fourth case of subconjunctival cilia entrapment in a patient with history of intraocular surgery and only the second following a conjunctival peritomy reported in the literature.7-9 The first case occurred in a patient after he had undergone surgery to repair a retinal detachment, while ours was after scleral tunnel cataract surgery. In a standard retinal detachment repair with peritomy, the entire conjunctiva is detached for 360 degrees. Our standard scleral tunnel cataract surgery peritomy is only 3 mm in width. Our case indicates that a foreign body can enter the subconjunctival space through a very small breach in the conjunctiva.
Subconjunctival cilia not entering through surgical incisions have been reported as early as 1921; however, the point of entry in that particular case was caused by another foreign body lacerating the bulbar conjunctiva.10 In another case, the eyelash entered after a subtenon injection was administered.11
Cicatricial conditions including ocular pemphigoid and symblepharon have also resulted in entrapment of lashes in the bulbar conjunctiva.9 Generally, removal is the treatment of choice regardless of cause but in cases where the patient was asymptomatic, no treatment was initiated.12
Our case highlights the fact that different incision techniques present unique complications. In the cases where clear corneal incision technique was used, cilia were retained in the anterior chamber.13,14 Because clear corneal incisions involve entering the anterior chamber via a corneal incision anterior to the limbus, there is little to no risk for a lash to become entrapped under the conjunctiva. When a scleral tunnel technique is used, it is more difficult for the eyelash to work its way into the anterior chamber but the peritomy may provide an entry point for a cilium or other foreign body to become trapped under the conjunctiva.
Our patient’s symptoms were mild but scleral ulceration and granuloma formation have occurred in cases of conjunctival entrapped cilia.11,15 It is important to do a thorough anterior segment examination following cataract surgery, not only of the incision site and anterior chamber, but of the entire globe. Knowledge of the surgical technique used may prove helpful when performing the post-operative examination. This information may prevent a benign problem from becoming a sight-threatening emergency.
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
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