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| CASE REPORT |
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| Year : 2021 | Volume
: 1
| Issue : 1 | Page : 135-136 |
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Gossypiboma of the eye
Madhu Kumar, Simakurthy Sriram, Ashok Kanakamedla, Jayamadhury Gudimetla, Anurag Shandil, Manit Agrawal
Department of Vitreoretina, Sankara Eye Hospital, Guntur, Andhra Pradesh, India
| Date of Submission | 19-May-2020 |
| Date of Acceptance | 30-Aug-2020 |
| Date of Web Publication | 31-Dec-2020 |
Correspondence Address:
Dr. Simakurthy Sriram
Department of Vitreoretina, Sankara Eye Hospital, Guntur - 522 509, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1566_20
A 50-year-old male patient with proliferative diabetic retinopathy with vitreous hemorrhage underwent vitrectomy with oil tamponade. At 1 week post-operative visit, we noticed a retained cotton fiber with adjacent exudation. Patient was started on oral steroids with a subsequent clearing of exudation within 2 weeks. Inadvertent foreign body implantation after an intraocular surgery occurs more frequently than expected. To date, there is no published report of retained cotton fiber in the vitreous cavity. We present a rare case of pre-retinal retained cotton fiber post-vitrectomy with resultant inflammation and its clinical course.
Keywords: Cotton fiber exudation, iatrogenic foreign body, intraocular foreign body, retained cotton fiber
How to cite this article:
Kumar M, Sriram S, Kanakamedla A, Gudimetla J, Shandil A, Agrawal M. Gossypiboma of the eye. Indian J Ophthalmol Case Rep 2021;1:135-6 |
A retained intraocular foreign body is of common occurrence post-trauma. However, retained intraocular foreign bodies are seen post intraocular surgeries as well. There are several documented cases of retained foreign bodies in the anterior segment, such as metal fragments,[1] cilium,[2] suture needle,[3] and cotton fibers[4] after phacoemulsification and laser-assisted in situ keratomileusis (LASIK).[5]
We present a case of retained cotton fiber stuck to the retinal surface after vitrectomy. To the best of our knowledge, such a case has not been reported so far.
| Case Report | |  |
A 50-year-old male, known case of both eyes proliferative diabetic retinopathy, was seen in our outpatient department. At presentation, his BCVA was 3/60 in the right and 4/60 in the left eye. He had immature senile cataract nuclear sclerosis of grade 2 in both the eyes. The patient had vitreous hemorrhage obscuring disc and macula in both eyes. The patient underwent vitrectomy with endolaser and oil tamponade in the right followed by the left eye with an interval of 2 months between two procedures. At 1-week post left eye vitrectomy, the patient had uncorrected visual acuity of 3/60 in the left eye. The anterior segment was quiet, with normal intraocular pressure in both eyes. On fundus examination retina was attached in both eyes with adequate oil fill, and left eye examination showed a cotton fiber strand over the disc and adjacent nasal retina with pre retinal exudates surrounding the cotton fiber. Left eye retina was attached. Swept-source optical coherence tomography (SSOCT) via cotton fiber showed the inflammatory reaction to be entirely pre retinal [Figure 1]. Patient was started on oral steroids (1 mg/kg body weight) in addition to a postoperative regimen consisting of topical antibiotics, steroid and a cycloplegic agent. At the end of 2 weeks, there was a total clearing of the exudation [Figure 2]. Patient was then posted for silicone oil removal in the left eye, and during the surgery, the fiber was removed using a cutter. Post Silicone oil removal, patient achieved BCVA of 6/18 in the left eye and is stable [Figure 3]. | Figure 1: (a) Fundus color photo showing pre retinal cotton fiber (red arrow) with adjacent exudation in an oil-filled eye (b) Red free image of the left eye highlighting the cotton fiber (red arrow) and exudation (in white) against the dark fundus background (c) swept-source OCT of the left eye showing pre retinal cotton fiber (red arrow) and adjacent pre retinal exudation
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 | Figure 2: Serial photographs showing an oil-filled eye with retained pre retinal cotton fiber (red arrow), resolution of exudation on the addition of oral steroids. (a) At presentation (b) at 1 week after steroid course (c) at ten days visit after steroid course (d) at 2 weeks after steroid course
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 | Figure 3: Serial fundus photographs of the left eye (a) At presentation - cotton fiber (red arrow) with adjacent exudation (b) 2 weeks after steroid course with resolution of exudation (c) 1 week post silicone oil and cotton fiber removal
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| Discussion | | |
A retained intraocular foreign body is a cause of concern, whether it is post-traumatic or post-surgical. They are a frequent cause of endophthalmitis.[2] Most of the post-surgical retained intraocular foreign bodies are metallic.[6] In contrast, retained intraocular cotton fibers are less commonly reported. In literature, retained cotton fiber in the anterior chamber and anterior vitreous is shown to be less reactive with minimal inflammation, predominantly consisting of mononuclear cells.[6],[7] Post-surgical retained cotton fibers in other body parts are documented to evoke an acute exudative and delayed aseptic fibrotic response known variably as 'Gossypiboma',[8] 'gauzeomas.'[9]
Cotton is commonly used during intraocular procedures as gauze pieces, in drape, to pack nasal bridge to prevent fogging of lenses during vitrectomy, and in making cotton-tipped applicators; and enter the eye during the exchange of instruments. Cotton fibers are sometimes tricky to identify intraoperatively; various reasons listed in the literature are corneal edema, glare from the pooling of the irrigating solutions, and the suboptimal contrast provided by the diffuse illumination beam of the surgical microscope.[6]
In our case, we noted the cotton fiber at the first post-operative visit, and it was associated with dense exudation around it. Though presence of exudation should point towards infective etiology, we hypothesize the exudate to be sterile because there was no anterior chamber or retinal inflammation, homing of exudate locally around the cotton fiber, and use of sterilized cotton on the operative table; and started the patient on a trial of oral steroids. There was a good response to oral steroids validating the hypothesis. Post vitrectomy, there is an inflammatory breakdown in the blood-retinal barrier allowing migration of the inflammatory cells from retinal blood vessels.[10] Use of plastic eye and trolley drapes, lint-free microfiber wipes for cleaning the instruments, separate sterilization of cotton-tipped applicators and gauzes from the surgical tray, and careful inspection of the vitreous cavity prior to removal of ports can help minimize the risk of retained intraocular cotton fibers.
A retrospective study has revealed that retained cotton fibers in the anterior segment are well tolerated and need not be removed.[6] In experimental studies done in rabbit, cotton fibers in anterior vitreous cavity evoked minimal inflammation; however, in our case, the patient had an intense inflammatory reaction. In our case, the patient had good response to addition of steroids, however in case of poor response or worsening, an infective etiology has to be kept in mind and an early surgical intervention to remove the fiber is warranted. One limitation of our report is that there is no histological correlation of the inflammatory response. There is a paucity of literature on the behavior of the cotton fiber in a vitrectomized eye.
| Conclusion | | |
The take-home message from our case report is the need for a thorough examination of the vitreous cavity before closing the case and at postoperative visits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Galloway GD, Ang GS, Shenoy R, Beigi B. Retained anterior chamber cilium causing endophthalmitis after phacoemulsification. J Cataract Refract Surg 2004;30:521-2. |
| 3. | Zacks DN, Foster BS, D'Amico DJ. A retained intraocular surgical needle 2 years after cataract extraction. Arch Ophthalmol 1999;117:691. |
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| 7. | Peiffer RL, Safrit HD, White E, Eifrig DE. Intraocular response to cotton, collagen and cellulose in the rabbit. Ophthalmic Surg 1983;14:582-7. |
| 8. | Rajagopal A, Martin J. Gossypiboma--”a surgeon's legacy”: Report of a case and review of the literature. Dis Colon Rectum 2002;45:119-20. |
| 9. | Chaya R, Okamura T, Nagai T, Kobayashi D, Kobayashi T, Akita H, et al. Case of a giant gauzeoma diagnosed 21 years after an inguinal hernia surgery. J Rural Med 2018;13:177-80. |
| 10. | Garner WH, Scheib S, Berkowitz BA, Suzuki M, Wilson CA, Graff G. The effect of partial vitrectomy on blood-ocular barrier function in the rabbit. Curr Eye Res 2001;23:372-81. |
[Figure 1], [Figure 2], [Figure 3]
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