visual outcome in siderosis bulbi

Visual outcome in a case of siderosis bulbi resulting from iron foreign body impacted in iris for ten years : 

Visual outcome in a case of siderosis bulbi resulting from iron foreign body impacted in iris for ten years Dr. Arvind Kumar, Dr. Mrinmoy Das, Dr.Shakun gupta, Dr. S.K.Tripathi Dr. B.K.Jain Shri Ram Chandraya Namah Shri Sadguru Parmatmane Namah

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None Financial disclosure

Introduction : 

Introduction When metal ions remained in the tissue for a long time can produce impairment of their function called METALLOSIS The common metallic foreign bodies which penetrate the eye are iron or steel, copper, aluminium, lead pellets Most frequently encountered metallosis is ocular siderosis1 1.Clinical ophthalmology, Jack J. kanski, 5th edition , 2003, 675

Introduction…. : 

Introduction…. Siderosis consists of chronic irreversible degenerative changes of the ocular tissues caused by retained intraocular Iron Epithelial structure is preferentially affected Iris impacted foreign bodies are not commonly encountered

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Mainly surgical Before surgical intervention 1.Circumstances of trauma 2.Foreign body characteristics (size, chemical composition and infectivity), 3.Lens status (clear or cataractous) and 4.Time of presentation should be evaluated If surgery is considered necessary, a technique which is most appropriate and least traumatic to the already injured eye, must be performed2,3. MANAGEMENT 2. Bishara SA, Nesher RG, Zelikovitch A. Extracapsular extraction and lens implantation for cataracts with foreign bodies. Ann Ophthalmol 1985;17:760-61.    [PUBMED]  3.Sneed SR, Weingeist TA. Management of siderosis bulbi due to a retained iron-containing intraocular foreign body. Ophthalmology 1990;97:375-79.    [PUBMED] Introduction….

Introduction…. : 

Introduction…. We have encountered a patient with iron foreign body impacted in iris for ten years The purpose of this paper is to report the visual outcome of this patient after proper management

Case report : 

Case report A 40 years male came to our hospital OPD presented with diminished near vision in left eye. On asking, patient gave history of trauma to right eye while chipping stone with a chisel and hammer 10 years back and managed medically elsewhere He also gave history of severe diminution of vision for distance and near since last 4 years in RE He had lost hope about regaining of vision in right eye

Case report…. : 

Case report…. On examination, visual acuity of right eye P.L.+ / P.R + , left eye 6/6. On non contact tonometer the intra ocular tension of RE and LE was 13.4 and 11.2 mmHg respectively On examination of left eye the anterior and posterior segment was with in normal limit

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On slit lamp examination of RE, lid and adnexa including conjunctiva was normal A full thickness scar at 12 o’clock, 2mm away from limbus and diffuse brownish staining of whole cornea was seen Case report….

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Brownish staining was limited to epithelium and anterior 1/3rd of stroma Anterior chamber was quiet, clear and normal in depth A small brownish black iron foreign body (2mm x 3mm) was seen impacted in iris at 12 o’clock Case report….

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Color of the iris was of reddish brown. Pupil was normal in size and showed no reaction to light , posterior synechiae was present from 10 to 1 o’clock There was rust spot on anterior surface of cataractous lens Case report….

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On Gonioscopic examination, angle appears to be open and pigmentation of the trabecular meshwork was present Fundus was not visible B scan showed normal posterior segment in right eye Case report….

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Patient underwent synechaeolysis, SICS with PCIOL implantation, foreign body removal and iridectomy at the site of foreign body impaction after proper counseling regarding unpredictable visual outcome and informed written consent Surgical procedure was performed by an experienced surgeon Case report….

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Postoperative medication comprised of use of antibiotic-steroid eye drop four times daily for one month and homatropine eye drop twice daily for 15 days. Vision improved to 6/24 next day and 6/12(BCVA) on 1st month follow up Case report….

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At one month follow up, eye was quiet and IOL in position with superior peripheral iridectomy and sluggishly reacting pupil Case report….

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On slit lamp biomicroscopy with + 90D, optic disc and macula was normal On indirect ophthalmoscopy there is no vascular attenuation and pigmentary changes Case report….

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Applanation tonometry-RE13,LE11mmHg Gonioscopy-open angle, pigmentation of trabecular meshwork visual field testing(30-2 SITA) showed a generalized constriction of field Case report….

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60-4 SITA strategy showed diffuse decrease in sensitivity and peripheral visual field constriction Case report….

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On OCT, nerve fibre layer thickness was normal in all quardant Case report….

Discussion : 

Discussion In siderosis bulbi the iris, lens, and retina can look rusty clinically and macroscopically The lens frequently is yellow-brown, with clumping of rusty material in the anterior subcapsular area (siderosis lentis) The iris can be stained leads to heterochromia iridis

Discussion…. : 

Discussion…. According to some authors deposition of iron in the sphincter of the iris leads to mydriasis4 On contrary to this, our patient presented with the fixed normal size pupil The cause may be posterior synechiae due to previous iritis 4.Parson’s diseases of the eye, R.Sihota, R.Tandon, 20th edition, 2003, 373

Discussion…. : 

Discussion…. The diminution of vision in siderotic eyes is due to degenerative changes in the retina and lens Retinal degeneration, attenuation of the blood vessels, eventually becomes generalized, resembling pigmentary retinal dystrophy4 But no such retinal changes seen in our case 4.Parson’s diseases of the eye, R.Sihota, R.Tandon, 20th edition, 2003, 373

Discussion…. : 

Discussion…. In this case, vision improved from PL+ / PR + to 6/12 at one month follow up This visual outcome and clinically normal retina may be due to the favourable location of foreign body as documented in literature that there is poorer visual outcome in posterior segment intraocular foreign body as compared to anterior segment foreign body5 5.Roy and Fraunfelder’s current ocular therapy, sixth edition, Saunder Elsevier, 2008, 289

Discussion…. : 

Discussion…. Findings of applanation tonometry, gonioscopy, fundus examination, OCT were unsupportive for diagnosis of glaucoma (subclinical siderosis secondary glaucoma7) but 30-2 SITA showed visual field changes like in late glaucoma 60-4 SITA strategy showed diffuse decrease in sensitivity and peripheral visual field constriction Therefore these visual field changes can only be explained by subclinical changes in neuroepithelial structures of retina 6.Knave B. Electroretinography in eyes with retained intraocular metallic foreign bodies: A clinical study. Acta Ophthalmol (Suppl). 1969;100:1–63. 7.Shair K, Ji SC, Sun XH. A clinical analysis of subclinical siderosis and secondary glaucoma. Chung Hua Yen Ko Tsa Chih. 1994;30:420-422

Discussion…. : 

Discussion…. So we can conclude that in long standing siderosis bulbi though there is good central vision, gross changes in visual field can occur Probably, an earlier surgical intervention can limit the damage to neuroepithelial structures in retina and improve visual outcome

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Thank You Acknowledgement for Suggestion – Dr Alok , Dr Ravi , Dr Suraj