Traumatic intracorneal foreign bodies are very common and account for 30.8% of all ocular injuries. Deeply embedded intracorneal foreign bodies have been documented in association with good final visual outcome when managed effectively. We report herein, an unusual case of possible spontaneously extruded deeply embedded intracorneal foreign body 5 weeks after sustaining a trauma to his right eye. Whether the foreign body was truly spontaneously extruded or absorbed by corneal tissue is unknown.

© 2023 The Author(s). Published by S. Karger AG, Basel

Traumatic intracorneal foreign bodies are very common and account for 30.8% of all ocular injuries [1]. Most ocular injuries are preventable with the use of protective eyewear [2]. Majority of traumatic intracorneal foreign bodies are superficial and mild causing little to no visual deterioration. Nonetheless, deeply embedded intracorneal foreign bodies have been documented in association with good final visual outcome when managed effectively [3].

Any traumatic foreign body carries higher risk for infection especially when caused by vegetative material. That is always a concern in the choice of treatment as well as in affecting final visual outcome, particularly if associated with fungal infections [4]. The current consensus in all publications of intracorneal foreign bodies of non-inert material is for effective surgical removal in various techniques [5, 6].

We report herein, an unusual case of possible spontaneously extruded deeply embedded intracorneal foreign body 5 weeks after sustaining a trauma to his right eye. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see www.karger.com/doi/10.1159/000528307.

A 12-year-old boy presented to our institution complaining of pain and redness of the right eye for 1 day. The patient has a history of sustaining a trauma 3 weeks earlier where he fell off his motorcycle and felt a mild blurring in vision which had improved spontaneously shortly after. On the examination, his visual acuity was 20/20 in both eyes with normal intraocular pressure. Anterior segment examination of the right eye revealed conjunctival injection with temporal paracentral deeply embedded small intracorneal foreign body reaching the endothelium layer with mild edema surrounding it (shown in Fig. 1a1, a2). The foreign body appeared to be of wooden organic material. An overlying small epithelial defect was noted with negative seidel’s test, and the presence of white blood cells in the anterior chamber was eminent. Pupil was regular and round with no iris defects, and lens was clear with no signs of violation. A thorough dilated fundus examination was normal and no intraocular foreign body was found. Anterior and posterior segment examination of the left eye was unremarkable. After ruling out the possibility of an open globe, further investigations were carried out to aid in accurately determining the level of the intracorneal foreign body. Anterior segment optical coherence tomography Topcon (AS-OCT) of the cornea was obtained showing the intracorneal foreign body to be deeply embedded, reaching the endothelium layer (shown in Fig. 1b). Due to the relatively long period between time of trauma and time of presentation and considering the depth of the foreign body, no surgical intervention was planned for him. The patient was placed on topical antibiotics (moxifloxacin QID) and close observation of twice weekly. Symptomatic improvement was noted throughout the follow-ups with no signs of infection. At 2-week follow-up, the patient reported spontaneous extrusion of the intraocular foreign body of which he had felt intense irritation then sudden improvement. On the examination, an extensive search was done looking for the foreign body in the anterior chamber and posterior chamber but only a remaining faint scar was found with a quiet eye, no intracorneal foreign body, and completely healed epithelium (shown in Fig. 1c).

a1 Slit lamp photo showing the deeply embedded intracorneal foreign Body. a2 A higher magnification slit lamp photo using diffuse illumination showing the intracorneal foreign body. b OCT anterior segment showing shadowing of the corneal layer corresponding to the level of the intracorneal foreign body reaching the endothelium. c A slit lamp photo at 2-weeks-follow up showing a remaining faint scar with no intracorneal foreign body.

Traumatic intracorneal foreign bodies are commonly encountered and reported to compromise 30.8% of all ocular injuries [1]. Variable types of foreign bodies can enter the cornea and management options can differ according to the nature of the intracorneal foreign body and how the cornea responds to the material involved [3].

While majority of cases are mild and superficial, deeply embedded foreign bodies carry a risk of perforation and should be handled with extreme caution [7]. Inappropriate interventions to remove deep corneal foreign bodies can induce corneal perforation [8]. Hence, treating physicians must weigh the risks and benefits of such procedures while taking into account the high risk of infections especially with some materials that are not well tolerated by the ocular tissues. It is advisable that such intervention procedures be carried out in a controlled environment in the operating room if the risk of perforation is expected.

In our case, we report an interesting finding of a possible spontaneous extrusion of the deeply embedded intracorneal foreign body 5 weeks after sustaining a trauma to his right eye. Lu and Taylor [9] reported the presence of nontraumatic three intracorneal foreign bodies that disappeared 1 year after presentation leaving a small deep scar. However, whether these foreign bodies were spontaneously extruded or absorbed by the corneal tissue is unknown; considering the nature of these foreign bodies was not mentioned in the report.

The use of anterior segment OCT can aid in determining the level of the intracorneal foreign body. A deeply embedded foreign body can be difficult to recognize with the use of slit-lamp biomicroscopy alone, especially, if it is accompanied by corneal opacity and edema [7]. In our case, anterior segment OCT aided in confirming the depth of the foreign body which directed the decision away from further manipulation and attempts of surgical removal. Additionally, given the age of the child; such manipulation carried higher risk of movement and lack of cooperation. Since the patient maintained 20/20 vision and there were no signs of active infection, the decision to observe such a case was taken. The next step in the stepwise care plan for this patient was surgical removal under general anesthesia in the operative theater.

Removal of intracorneal foreign bodies is always ideal when successful removal can be safely performed to prevent infections and complications. However, is observation a good management plan in cases with higher risk of perforation or lack of significant visual consequences? How does the cornea expel non-inert material with its remodeling and what is the expected time frame for such phenomenon? These are questions we have yet to answer as these cases are not often managed conservatively. If sufficient cases and data arise on such matter and self-extrusion is in fact a recurring pattern, perhaps observation of intracorneal foreign bodies might be advisable in certain circumstances.

In summary, we report an interesting finding of a possible spontaneous extrusion of a deeply embedded intracorneal foreign body 5 weeks after sustaining a trauma to his right eye. This study proposes the possibility of self-extrusion of intracorneal foreign bodies and highlights the importance in weighing the risks and benefits of intracorneal foreign body removal while taking into account the high risk of infections.

Written informed consent was obtained from the parent/legal guardian of the patient for publication of the details of their medical case and any accompanying images. Any sort of information that might reveal the patient’s own identity has been completely avoided. This retrospective review of patient data did not require ethical approval in accordance with local/national guidelines.

The authors have no conflicts of interest to declare.

The authors have no funding sources to disclose.

The authors confirm sole responsibility for the following: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation. Dr. Abeer A. AlHazzani and Dr. Dalal R. Fatani contributed to design, data collection, analysis and interpretation of results, and manuscript preparation. Dr. Hatem Kalantan contributed to the data acquisition and supervision of the study. All the authors approved the final version.

All data generated and analyzed during this study are included in this article and its online supplementary material. Further inquiries can be directed to the corresponding author: Dr. Abeer A. Alhazzani.

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