The associated lid abnormality is an interesting feature.Filtering blebs may present many years after penetratingtrauma5, but the patient had no such history and on speak-ing to her parents confirmed she had not sustained aninjury as an infant. Scleroderma may produce lid distortionand madarosis, and there is one case report of a patientwith linear scleroderma developing a spontaneous bleb;however, this patient also had atrophy of the inferioroblique and superior rectus and ‘en coup de sabre’.6

The cause of the bleb in our patient remains unclear;however, the case demonstrates the usefulness of ultra-sound biomicroscopy in differentiating a bleb from a con-junctival cyst.

Andrew Tatham FRCOphth,Wojciech Karwatowski MD FRCOphth and

Periyasamy Kumar FRCS(Ophth)(Ed)University Hospitals Leicester,

Infirmary Square, Leicester, UKReceived 8 January 2011; accepted 16 January 2011.

REFERENCES

1. Mantravadi AV, Stock EL. Spontaneous filtration blebas a consequence of scleritis. Arch Ophthalmol 2007; 125:1578–9.

2. Wong VA, Beiko G, Pavlin CJ, Rootman DS. Treatmentof a spontaneous filtering bleb due to Terrien’s marginaldegeneration with injection of autologous blood. Can JOphthalmol 1995; 30: 377–9.

3. Nemet P, Bracha R, Lazar M. Spontaneous filteringblebs in Axenfeld syndrome. Am J Ophthalmol 1973; 76:590–1.

4. Jonas JB, Ruprecht KW, Schmitz-Valckenberg P et al.Ophthalmic surgical complications in Werner’s syn-drome: report on 18 eyes of nine patients. OphthalmicSurg 1987; 18: 760–4.

5. Khouri AS, Newman FR, Fechtner RD. Ultrasoundbiomicroscopy demonstrating etiology of a spontaneousfiltering bleb. Eye (Lond) 2006; 20: 1441–2.

6. Gerke E, Meyer-Schwickerath G, Joussen F. [Scleroder-mie en coup de sabre with spontaneous filtering bleb(author’s transl)]. Klin Monbl Augenheilkd 1976; 168:426–8.

Retained metallic foreign bodiesafter phacoemulsification

Retained metallic fragments following phacoemulsifica-tion are rare.1 We report a case of retained metallic foreign

bodies (FB) following cataract surgery with a new genera-tion phacoemulsification unit and update current knowl-edge on the nature of the FBs and their management.

A 91-year-old man underwent phacoemulsification for adense nuclear sclerotic cataract in his right eye. A metallicFB < 0.5 mm size was observed on the peripheral iris at the7 o’clock position at the beginning of phacoemulsification(Alcon Infiniti Vision; 45 Degree Kelman 1.1 flared ABStip, Ft. Worth, TX, USA) (Fig. 1). The FB was not aggres-sively pursued for removal. The cataract surgery was com-pleted without complication. On the first postoperativeday, visual acuity (VA) in the right eye was 6/21; slit-lampbiomicroscopy was notable for peripheral corneal oedema,which precluded a detailed view of the peripheral iris. Thedilated fundus examination was unremarkable. At 1-weekfollow up, the VA in the right eye was 6/6 and the slit-lampexamination showed resolution of corneal oedema andmultiple metallic FBs all less than 0.2 mm in size on thesurface of the peripheral iris (Fig. 2). No FBs were seen inthe angle on gonioscopy. B-scan ultrasonography of theposterior segment did not disclose any additional FBs inthe eye. The options of observation versus removal werediscussed with the patient and he elected conservativemanagement. At 10 months postoperatively, the patient’sVA was 6/6 with a stable examination in the right eye; themetallic FBs remained unchanged.

In this case, metallic FBs were noted during phacoemul-sification and postoperatively. They are most likelytitanium (Ti) derived from the 100% grade 5 Ti pha-coemulsification tip with anodized surface as a secondinstrument was only utilized near the conclusion of pha-coemulsification after the FB were already observed.1,2 A Tifragment from phacoemulsification tip can be identified byits irregular shape, metallic luster and the correspondingdefect on the phacoemulsification tip that can be confirmedby slit-lamp.1 The composition of a FB is important: there

Financial support: This material is the result of work supported with resources and the use of facilities at the VA Medical Center, Providence,

RI.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of theUnited States

(US) Department of Veterans Affairs or the USGovernment.

Figure 1. Metallic intraocular foreign body at the 7 o’clockposition during phacoemulsification.

Letters to the Editor 713

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists

is a risk of toxic anterior segment syndrome if it is com-posed of elements such as sodium, chlorine, phosphorous,sulfur and calcium. Such FBs are thought to be chemicallyaltered fragments of ophthalmic viscosurgical device andappear opaque white.3 In contrast, the Ti fragments from aphacoemulsification tip are made of Ti 6AL-4V ELI (grade5) alloy, which is considered to be inert.4 Future magneticresonance imaging compatibility is another key clinicalissue, especially in light of the current 3–4 Tesla magnetsbeing used for imaging. The Ti 6AL-4V ELI (grade 5) hasno known magnetic properties and is commonly used inorthopedic and dental implants.1,4

A recent report recommended that a larger (2 mm)steel/titanium alloy Rosen chopper tip fragment FB beremoved surgically because of its dislocation from theciliary sulcus into the anterior chamber.5 However, ourcase demonstrates that conservative management of smallphacoemulsification tip metallic FBs is a viable optionbecause of their inert nature and compatibility with anyneed for future neuroimaging. Ultimately, the clinicaldecision to remove a FB associated with phacoemulsifi-cation should involve consideration of the FB source, sizeand location.

Yasir Ahmed BS,1,2 Vijay Khetpal MD,3

Peter Fay MD1 and Paul B Greenberg MD1,2

1Section of Ophthalmology, VA Medical Center, 2Division ofOphthalmology, Warren Alpert Medical School ofBrown University, Providence, Rhode Island, and

3Department of Ophthalmology, University of Florida,College of Medicine, Jacksonville, Florida, USA

Received 18 January 2011; accepted 24 January 2011.

REFERENCES

1. Braunstein RE, Cotliar AM, Wirostko BM, Gorman BD.Intraocular metallic-appearing foreign bodies afterphacoemulsification. J Cataract Refract Surg 1996; 22:1247–50.

2. Köse S, Mentes J, Uretmen O, Topçuoglu N, Köktürk U,Yilmaz H. The nature and origin of intraocular metallicforeign bodies appearing after phacoemulsification.Ophthalmologica 2003; 217: 212–4.

3. Mathys KC, Cohen KL, Bagnell CR. Identification ofunknown intraocular material after cataract surgery:Evaluation of a potential cause of toxic anterior segmentsyndrome. J Cataract Refract Surg 2008; 34: 465–9.

4. Niinomi M. Recent metallic materials for biomedicalapplications. Met Mater Trans A 2002; 33: 477–86.

5. Varma DK, Shaikh VM, Hillson TR, Ahmed IIK. Migra-tion of retained broken chopper tip after phaco-emulsification. J Cataract Refract Surg 2010; 36: 857–60.

Retained releasable suture causinginfectious keratitis followingtrabeculectomy

There are many risk factors for bacterial keratitis, and thesehave wide climatic and geographical variation. Commonrisk factors are trauma, prior ocular surgery, ocular surfacedisease, eye lid disorders and contact lens wear.1,2 Wereport a case of bacterial keratitis where the infection wascaused by the protruding end of the releasable scleral flapsuture used in trabeculectomy.

A 60-year-old lady was diagnosed with chronic angleclosure glaucoma and cataract in both the eyes. At presen-tation, her best-corrected visual acuity was 6/10 and N6 inboth eyes. She was non-diabetic and non-hypertensive,and medical history was not significant for any other sys-temic illness. After YAG peripheral iridotomy, dilatedexamination revealed significant nuclear sclerosis in righteye. Both the eyes had near total cup with advanced visualfield defect. Because of refractory glaucoma she was oper-ated for combined cataract extraction and trabeculectomywith 5-flurouracil in right eye. Despite good recovery ofvisual acuity, the filtration bleb failed but intraocular pres-sure was subsequently controlled with topical 0.03%bimatoprost in right eye. Nearly a year and half later sheunderwent trabeculectomy with releasable suture in lefteye for uncontrolled glaucoma. The releasable suture (10-0monofilament nylon) was fashioned by first passing itwithin the corneal stroma, forming an intracornealpassage, before being taken out of the cornea, and passingit through the conjunctiva and the scleral flap. The cornealend of the suture was cut flush with the corneal surface.During the postoperative course the bleb becameencapsulated. This was treated with oral acetazolamide250 mg four times a day, topical 0.05% timolol twice dailyand topical betamethasone six times per day. The releas-able suture was not removed and she was kept underfortnightly review.

During this period when encapsulation was beingtreated, about 3 months after the operation, she presentedwith sudden onset of pain, redness, watering and decreasein vision in the left eye of 4-day duration. Visual acuity in

Figure 2. Multiple metallic foreign bodies on the peripheral irisobserved on 1-week follow up.

714 Letters to the Editor

© 2011 The AuthorsClinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists