Management of Descemet’s penetrating wooden foreign body in a child using vitreoretinal forceps

A 6-year-old male child presented with a history of trauma to the right eye (OD) with a wooden stick 2 days ago. On examination, uncorrected visual acuity (UCVA) in OD was 6/6, N6; and finger tension was within normal limits. A slit-lamp examination showed a 0.5 mm × 2 mm wooden foreign body (FB) with an entry wound in the cornea, sparing the visual axis, and appearing to be breaching Descemet’s membrane (DM) and entering the anterior chamber [Fig. 1a]. There was minimal infiltration at the tip of the FB.Figure 1: (a) Slit-lamp photo of the cornea taken with indirect illumination showing intracorneal foreign body. (b) Anterior segment optical coherence tomography (AS-OCT) done in horizontal scan showing hyperreflective corneal foreign body with entry site along with backshadowing [orange arrow] and inward curling of Descemet’s membrane [white arrow]. (c) AS-OCT done in vertical scan showing hyperreflective foreign body breaching Descemet’s membrane and entering the anterior chamber [white arrow]Anterior segment optical coherence tomography (AS-OCT) showed hyperreflective corneal FB with backshadowing [Fig. 1b], breaching DM, and entering the anterior chamber [Fig. 1c]. A DM breach is marked by the inward curling of DM.[1] The posterior segment of OD was within normal limits. The child was started on vigamox 0.5% eye drops 6 times/day, tobramycin 0.3% eye drops 6 times/day, and natamycin 5% eye drops 4 times/day. In the operation theatre, the site of the FB entry was marked. General anesthesia was induced, a 27-gauge needle was used to create a tract, and end-grasping forceps with a sharp, triangular tip [Fig. 2a] were used to hold and remove the wooden stick in totality [Fig. 2b and c]. A microleak of aqueous was noted, and the site of FB removal was closed with two 10-0 nylon sutures. The anterior chamber was well formed, and finger tension was within normal limits. Postoperatively, on day 1, the UCVA was 6/6, and a slit-lamp examination revealed a quiet eye and two sutures at the site of the removal of FB [Fig. 2d].Figure 2: (a) 23-G end-grasping forceps which were used to remove the intracorneal foreign body. The zoomed-in picture at the upper right corner shows the triangular tip of forceps. (b) Intraoperative picture showing removal of foreign body in totality using 23 G end grasping forceps. (c) Dimension of removed corneal foreign body (~2 mm) taken using a sterile scale under the operating microscope. (d) Postoperative day 1 picture showing two 10-0 nylon sutures at the site of foreign body removal with a deep anterior chamberDiscussion AS-OCT delineates the exact depth of anterior chamber penetration, path, orientation of FB, and any breach in DM. The edge of the wooden FB is hyperreflective with a variable shadow effect depending on the compactness of the wood. Hyperreflective areas with no shadowing effect are unlikely to be due to foreign objects.[1] En bloc removal of wooden particles should be ensured to prevent possible infectious keratitis and vision-threatening complications. Removal of wooden foreign bodies from the deep corneal stroma using vitreoretinal FB forceps as a scoop ensures complete removal of FB and has been described as a safe technique.[2] We used forceps with a triangular tip for firmly grasping the FB and removing it using the anterior approach as the entry route was visible subepithelially clinically. The ab externo approach was preferred to avoid slippage of FB as well as spillage of infection in the anterior chamber. Removal of a thin sliver of DM penetrating a wooden FB was possible in totality in a single attempt by using end-grasping forceps. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.