Occult nonmetallic intraocular foreign bodies presenting as fulminant uveitis: a case series and review of the literature
A 13 year old boy initially presented to an external provider with 3 weeks of redness, pain, photophobia, floaters in his left eye, and with a VA of 20/60. Despite topical and systemic corticosteroids, the patient’s VA worsened. As a result, he was referred for further evaluation and management 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. Initially he was treated with cycloplegics and topical steroids. Later, 40 mg/day of oral prednisone and double strength Bactrim were added to cover possible toxoplasmosis due to a history of exposure to cats. Despite treatment, his vision and symptoms worsened. Examination revealed a normal OD. His left eye had hand motions VA with a nasal visual field deficit, pressure of 9, conjunctival injection, 4+ AC cell, 0.5 mm hypopyon, pupillary membranes, and no view to the posterior pole. B-scan ultrasound revealed a diffusely thickened choroid, vitreous debris, subretinal fluid, posterior vitreous detachment, and areas of minor traction but no apparent foreign body. Laboratory work up was negative for sarcoidosis, Lyme disease, HLA B27, toxoplasmosis, and Bartonella. Further treatment consisted of 80 mg of oral prednisone daily, difluprednate 0.05% four times daily, and atropine 1% twice daily. The patient failed to improve, so he underwent pars plana vitrectomy, lensectomy, vitreous biopsy, intravitreal injection of antibiotics (vancomycin and amikacin), endolaser, and silicone oil injection. A foreign body (histologically consistent with hair) was discovered in the vitreous and removed. Gram stain and cultures were negative. His postoperative course was complicated by a total retinal detachment requiring a second surgery which was unsuccessful. On follow-up, the patient denied pain, his VA remained at the hand motions level, and there was no evidence of ongoing inflammation on exam.