Longstanding iris foreign body to treat or not to treat

A 61 year female presented with whitish discolouration of left eye noticed few days ago with a forgotten history of trauma 28 years ago for which a consultation was made and was asked for review with orbital x-ray, which was not done as she was asymptomatic. On examination, her best corrected visual acuity was 6/6 both eyes. Examination of right eye was unremarkable except for early lens changes, while left eye showed a nebular corneal opacity, suggesting entry wound. A brown coloured foreign body was seen stuck to iris surface temporally, measuring 4*3mm with degenerative changes over it and exposing underlying pigment epithelium with focal cataract. Rest of anterior segment, gonioscopy and fundus examination were normal. A thorough search for other intraocular foreign bodies (IOFBs) was made, revealing no other IOFBs. Anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) demonstrated foreign body limited to iris surface, while orbital x-ray showed no evidence of metallic foreign body and electroretinogram (ERG) showed mildly decreased amplitude of b-wave. Plan for foreign body removal with cataract surgery was made as per patient’s request for cosmesis, and was retrieved through viscoexpression after a failed attempt to remove it through magnetic forceps thereby confirming its non-metallic nature. Special care was taken during capsulorhexis to not damage the intact capsule. Rest of cataract surgery was performed as usual and anterior chamber wash was done to flush all the debris. Post operative picture shows an area of partial and full thickness iris defect while maintaining a good visual acuity. The debate for removal of longstanding, well encapsulated, inert foreign body over iris without functional impairment depends on multiple factors. [1,2] Which in our case was due to the patient’s demand for cosmesis. Video link: https://youtu.be/pC3ZRoqxB8o