Abstract
Purpose
To report a case of retained anterior chamber graphite foreign body with subsequent inflammation 20 years later.
Observations
A 29-year-old female who presented with first episode of acute blurring of vision and eye redness was noted to have a retained intraocular graphite foreign body in her anterior chamber. She recalled being accidently hit by a mechanical pencil 20 years ago.
Conclusions and importance
Retained intraocular graphite foreign bodies are inert and generally do not cause inflammation. This is the longest reported duration of retained anterior chamber graphite foreign body that developed subsequent inflammation and corneal endothelial damage only 20 years later.
1
Introduction
Intraocular foreign bodies are not uncommon, accounting for 28.6 % of all open globe injuries. Whilst organic foreign bodies are often associated with severe inflammation, the inflammation generated by inorganic foreign bodies depend on its material. Inert foreign bodies such as glass, plastic may remain quiescent for an extended period of time. Pencil lead consists of graphite, wax, clay and animal fat. Graphite, the main constituent, is inert and has been demonstrated to generally not cause any reaction in the eye for years. However, retained pencil lead in the vitreous cavity has been reported to result in possible sterile endophthalmitis, presumably due to the aluminium component in pencil lead. Potential toxicity of the other components of pencil lead remains unclear. Retained intraocular graphite is rare and only a few case reports exist. To our knowledge, this is the first report of an anterior chamber graphite foreign body that was retained for 20 years, the longest reported duration thus far, with subsequent development of inflammation.
2
Case report
A 29-year old Malay female presented to the Emergency Department with painless blurring of vision and redness of the left eye of one day duration. She denied any history of ocular trauma. Past medical history was negative. On examination, her visual acuity (unaided) was 6/6 in the right eye and 6/24 with improvement with pinhole to 6/9 in the left eye. Intraocular pressure was 16 mmHg in the right eye and 13 mmHg in the left eye. Slit lamp examination of her left eye revealed circumcillary conjunctival injection, a small inferior cylindrical black foreign body measuring 1.3mm vertically by 0.6mm horizontally in her anterior chamber ( Figs. 1–3 ) associated with mild cellular activity and inferior corneal touch. There were scattered keratic precipitates, inferonasal peripheral anterior synechiae and pigments on the lens capsule. No hypopyon was noted. There was presence of an old full-thickness corneal shelving wound inferiorly with multiple small intrastromal black particles and inferior epithelial microcysts of the cornea adjacent to the site of the foreign body.
On further history taking, she reported that she was hit in her left eye 20 years ago by a mechanical pencil that was accidently thrown by another child in school. She did not seek medical attention at that time and had no intervening ocular symptoms until time of presentation. No relative afferent pupillary defect was noted and posterior segment examination was unremarkable. Anterior chamber optical coherence tomography showed presence of an old full-thickness corneal wound with an inferior anterior chamber foreign body ( Fig. 4 ). Corneal pachymetry was 556 μm in the right eye and 575 μm in the left eye. Specular microscopy demonstrated a low endothelial cellular density of 710mm 3 as compared to 2445mm 3 in the right eye. The right eye was normal on examination.
She had a retained intraocular graphite foreign body for 20 years’ duration in her anterior chamber, which was quiescent for many years, with delayed inflammation and endothelial cell damage 20 years after the initial insult. She was started on topical Moxifoxacin 0.5 % eyedrops as prophylaxis against possible infection, and Prednisolone acetate 1 % eyedrops every 3 hourly to her left eye. There was improvement of the inflammation in her left eye with topical eyedrops ( Fig. 5 ).
