A 45-year-old man presented with a 12-h history of a transverse irregular corneal laceration from 3 o’clock to 9 o’clock position with iris and vitreous prolapse after being hit by a piece of iron in the left eye. The wound was closed by primary repair of corneoscleral laceration on the first presentation day. His left eye had best corrected visual acuity (BCVA) of no light perception. Slit-lamp examination presented chemosis, corneal edema, disappearance of anterior chamber, intraocular hemorrhage, and traumatic cataract. Fundus details were not clear due to severe vitreous hemorrhage. B-scan ultrasonography identified a hyperechogenic shadowing that was concerning for an IOFB (Fig. 4.11a). Computed tomography showed a metallic IOFB in the vitreous (Fig. 4.11b). Examination of the right eye was unremarkable.

Eight days after primary repair, we removed the IOFB through an open-sky corneal incision followed by a 23-gauge pars plana vitrectomy (PPV) using a TPK. Firstly, the irrigation-aspiration was performed for removing the exudates and hemorrhage in the anterior chamber (Fig. 4.11c). Then injured cornea was excised using a 7.25-mm trephine (Fig. 4.11d), and the corneal graft was protected by a viscoelastic material and kept in a humid container. After the inflammation tissue of the anterior segment was removed, the IOFB appeared and was separated completely from all surrounding tissues. Then it was grasped with forceps and extracted through the open-sky corneal incision (Fig. 4.11e, f). PPV was performed by using a TPK which included membrane peeling, use of perfluorocarbon liquids, photocoagulation, and silicone oil filling. At the end, the patient’s injured corneal graft was sutured back with 10-0 Vicryl suture.

Removal of a giant IOFB by the traditional technique usually requires a relatively large sclerotomy which can damage the ciliary body and peripheral retina because it is difficult to precisely locate the position of the IOFB and fully expose the posterior globe wall [10]. Similarly, removal of a giant IOFB through the corneal limbus incision combined with PPV also has their limitations. Kunikata et al. [11] showed two cases of 25-gauge microincision vitrectomy surgery for removal of large IOFB through the 2.4- or 3.0-mm corneal incision. However, this technique is best suited to long slender smooth foreign body and cannot be used for giant and irregular-shaped foreign body.

In this case, open-sky approach presents the following advantages. Firstly, it allows easy and direct access to the giant IOFB, so that the surgical damage to retina, ciliary body, or other ocular structures can be avoided. Secondly, the surgeon can grasp the giant IOFB easily and steadily with forceps, which prevented accidental slippage. Thirdly, it is a useful method in treating patients with giant IOFBs complicated with severe corneal opacity and laceration. The limitation of our method which is open-sky approach itself might threaten the healing of cornea incision and neovascularization.

A 49-year-old man presented with a progressive blurred vision, pain, photophobia, and redness in the left eye for 10 years and worsened for 3 months. He had a history of penetrating injury in the left eye 10 years ago and was diagnosed traumatic cataract and IOFB. There was no information about the ophthalmic examination and ocular symptoms of the patient at that time. He underwent a successful cataract surgery and intraocular lens implantation 5 months after the injury. However, it was unknown whether the foreign body was removed or not. Three months ago, he returned with visual impairment and intraocular inflammation in the left eye, and topical antibiotics and medical treatment were given for photophobia, pain, and redness. However, the symptoms were not alleviated. On presentation, the visual acuity was light perception and IOP was 46 mmHg in the left eye. The left eye examination revealed chemosis, corneal edema, flare in the anterior chamber, and stale iris laceration. The fundus was not clear. Ocular ultrasonography demonstrated only a vitreous opacity in the left eye (Fig. 4.12a). Neither X-ray nor CT revealed an IOFB (Fig. 4.12b). Systemic and topical antibiotics as well as steroids were given, but no improvement was seen in vision and sign. Because of a clinical suspicion of an IOFB in posterior segment and secondary glaucoma, a 23-gauge vitrectomy combined with trabeculectomy was performed. A 2-mm long metallic foreign body was found at 6 o’clock of ora serrata and was removed from the sclerotomy site (Fig. 4.12c, d). The stale iris laceration induced by IOFB and iridectomy for trabeculectomy was seen clearly (Fig. 4.12d). Two months after the foreign body removal, the symptoms of uveitis and glaucoma disappeared. The final BCVA was 20/100 and IOP was 13 mmHg without intraocular inflammation (Fig. 4.12f). The visual field defect significantly appeared at the final follow-up (Fig. 4.12g).

As a general rule, a fresh IOFB should not be left in the eye after open-globe injury. However, if the IOFB is verifiable inert, and no signs of endophthalmitis was observed, early surgery should be considered carefully for its risk of potential complications may possibly bring more damage to the eye than the IOFB itself. In cases of posterior segment IOFBs, a decision of vitrectomy or not must be made in time: the more severe tissue damage is, the more indication of vitrectomy is given to remove the IOFB and prevent subsequent damage to the intraocular structure [12]. An invisible IOFB due to severe vitreous hemorrhage or inflammation is an absolute indication. Furthermore, decisions must be made depending on the condition of instruments, surgical timing, and preoperational prophylactic antibiotics [13].

The surgical plan should be well discussed once the IOFB has been accurately localized. Some IOFBs may be well tolerated, such as glass particles or alloys, and a decision of observation could be made in the first instance. This especially applies when the visual acuity remains fine. When an IOFB is decided not to be removed immediately, intravitreal antibiotics is wildly accepted and used as a prophylactic measurement against infectious endophthalmitis [14]. IOFBs in the posterior segment require to be carefully analyzed for the risks of endophthalmitis. Ophthalmologist should also consider the surgeon’s experience and expertise, the equipment availability (at night versus in the daytime), the patient’s general condition, and the legal environment [13].