Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature
A 10 year old boy presented with 2 weeks of pain, pressure sensation, photophobia, and redness without discharge in the left eye and a VA of 20/150. He was initially treated with topical and systemic corticosteroids. Despite treatment, his symptoms progressed and after one week his VA had worsened. He was then referred to a tertiary care center. Despite extensive questioning of both parents and patient, the patient denied any history of trauma, and the patient had no systemic symptoms. Examination of his right eye was unremarkable. His left eye had a VA of 20/300 and an IOP of 5. Examination of his left eye revealed conjunctival injection, 4+ AC cell, and 0.1 mm hypopyon. Fundus detail was obscured by vitreous haze. B-scan ultrasound was remarkable for mild vitritis but did not demonstrate a foreign body. The patient underwent an investigation for infectious and inflammatory causes including Herpes simplex virus, Varicella zoster virus, Cytomegalovirus, cat-scratch disease, Lyme disease, toxoplasmosis, toxocariasis, juvenile idiopathic arthritis, tubulointerstitial nephritis-uveitis, syphilis, and sarcoidosis, and each test was negative. He was initially treated with systemic azithromycin and valacyclovir but did not improve. As a result, he then underwent surgical exploration and vitrectomy with intravitreal injections of vancomycin, voriconazole, ceftazidime, and foscarnet. Although no signs of trauma or other injury were found during surgery, a hairlike intravitreal IOFB discovered during surgery was removed and sent to pathology. This IOFB was confirmed by pathology to be an eyelash. Vitreous cultures and PCR revealed methicillin sensitive Staphylococcus aureus. The patient was treated postoperatively with systemic dicloxacillin 500 mg four times daily, prednisone 20 mg daily with a rapid taper along with topical 1% atropine daily, and difluprednate 0.05% four times daily. Three weeks following surgery, the patient was pain-free, and his ocular inflammation was reduced to only 1+ cell in the AC. He later developed a total tractional retinal detachment that required surgical repair. Over the following 2 years the patient remained pain-free, and the eye remained quiet with hand motions VA in his left eye.