severe ocular trauma requires emergency surgery , and a fresh corneal graft may not always be available . we describe a case of perforating eye injury with corneal opacity , suspected endophthalmitis , and an intraocular foreign body . the patient was successfully treated with a two - step procedure comprising endoscopy - guided vitrectomy followed by corneal transplantation . this surgical technique offers a good option to vitrectomy with simultaneous keratoplasty in emergency cases where no graft is immediately available and there is the possibility of infection due to the presence of a foreign body . a 55-year - old japanese woman was referred to our hospital with a perforating corneal and lens injury sustained with a muddy ferrous rod . vitreoretinal surgery was required due to suspected endophthalmitis , vitreous hemorrhage , retinal detachment , dialysis and necrosis of the peripheral retina . instead of conventional vitrectomy , endoscopy - guided vitreous surgery was performed with the solid fiber catheter as-611 ( fibertech , tokyo , japan ) due to the presence of corneal opacity and the unavailability of a donor cornea . the retina was successfully attached with the aid of a silicon oil tamponade . following removal of the silicon oil at 3 months after surgery , penetrating keratoplasty and intraocular lens implantation with ciliary sulcus suture fixation were performed . at 6 months after penetrating keratoplasty , the graft remained clear and visual acuity was 20/40 . primary endoscopic surgery for vitreoretinal complications in eyes with perforating injury performed prior to penetrating keratoplasty appears to be advantageous in terms of avoiding damage to the corneal endothelium . severe ocular trauma requires emergency surgery , and a fresh corneal graft may not always be available . we describe a case of perforating eye injury with corneal opacity , possible endophthalmitis , and an intraocular foreign body successfully treated with a two - step procedure comprising endoscopy - guided vitrectomy followed by corneal transplantation . a 55-year - old japanese woman was referred to our hospital with a perforating corneal and lens injury sustained while carrying a muddy ferrous rod . on initial examination , her best - corrected visual acuity ( bcva ) was light perception in the right eye . slit lamp examination revealed a penetrating corneal and lens injury in the 5.30 oclock position on the temporal side , but no foreign bodies . primary corneal sutures , anterior vitrectomy and lensectomy were performed as emergency procedures . written informed consent was obtained from the patient for the surgical procedures , examinations , and treatment modalities throughout her admissions and follow - up examinations . the patient was discharged after 6 days and prescribed topical levofloxacine qid ( cravit , santen pharmaceutical co , osaka , japan ) , betametasone qid ( rinderon , shionogi , osaka , japan ) and tropicamide plus phenylephrine hydrochloride tid ( mydrin p , santen ) . postoperative visual acuity was hand motion in the right eye and intraocular pressure was within the normal limits . four days after being discharged , the patient complained of ocular pain . a follow - up examination at the outpatient clinic revealed corneal edema , hyphema , and the presence of cells in the anterior chamber . in addition to oral acetazolamide at 1000 mg / day ( diamox , sanwa kagaku kenkyusho , nagoya , japan ) the patient was also prescribed 0.5% timolol bid ( timoptol , santen , japan ) and 1% brinzolamide eye drops bid ( azopt , alcon japan , tokyo , japan ) . the patient received 300 ml of iv mannitol over the following 11 days due to uncontrollable intraocular pressure . increase in corneal edema , the appearance of + + + cells and fibrin exudates in the anterior chamber led to a tentative diagnosis of endophthalmitis with secondary ocular hypertension ( figure 1 ) . vitreoretinal surgery and removal of the vitreous hemorrhage were planned for suspected endophthalmitis . instead of conventional vitrectomy with simultaneous keratoplasty , endoscopy - guided vitrectomy was considered due to the presence of corneal opacity , the lack of availability of a donor cornea , and the potential for excessive corneal endothelial damage to occur during a combined vitrectomy and keratoplasty procedure . endoscopy - guided vitreous surgery was performed using the solid fiber catheter as-611 ( fibertech corp , tokyo , japan ) . endoscopic examination revealed diffuse whitening of the vitreous body , retinal edema , dot hemorrhages , and multiple foci of peripheral retinal dialysis extending 360 degrees . endoscopic examination also revealed a 3.5-mm linear brown elastic object associated with white surrounding fibrin and an area of retinal necrotic dialysis located anterior to the equator in the 5.30 oclock position . areas where there was retinal dialysis or retinal necrosis peripheral to the penetration site were treated with green yag laser endophotocoagulation and gas - fluid exchange , followed by a 4.2-ml silicon oil tamponade . the exchange fluid contained 20 g / ml vancomycin ( shionogi ) and 40 g / ml ceftazidime hydrate ( modacin , glaxosmithkline , tokyo , japan ) . intravitreal injection of 10 mg / ml vancomycin and 20 mg / ml ceftazidime hydrate was also carried out . figure 2 shows the post - treatment features of the area observed by endoscopy near the penetrating injury where the foreign body and peripheral retinal dialysis were found . japanese iridectomy was performed at 6 oclock , followed by closure of the vitrectomy ports with 7/0 dexon sutures . subconjunctival injection of 10 mg / ml vancomycin and 20 mg / ml ceftazidime hydrate and ofloxacin ophthalmic ointment ( tarivid , santen ) were carried out . no pathological organisms , including bacteria or fungi , were identified in microbiological cultures from the extracted intraocular foreign body or vitreous sample . landolt uncorrected visual acuity in the right eye was 20/400 and iop was 16 mmhg without administration of anti - glaucoma drops at 3 months after surgery . penetrating keratoplasty and intraocular lens implantation with ciliary sulcus fixation were performed when a local donor graft became available one year later . the patient was prescribed topical levofloxacine qid ( cravit ) , topical betamethasone qid ( rinderon ) , and 0.1% topical sodium hyaluronate ( hyalein , santen ) eye drops qid . at 6 months postoperatively , the graft remained clear and bcva was 20/100 + 1.25  5.0 95 . the patient was prescribed a spheric + 3.50d hard contact lens with a base curvature of 8.6 mm and a diameter of 9.8 mm due to irregular astigmatism . a temporary keratoprosthesis during vitreoretinal surgery may be used in cases where the eye has sustained a perforating corneal injury and potential vitreoretinal pathologies may be hidden from view.1 combined vitrectomy and simultaneous keratoplasty have been reported to be beneficial.2 however , an open - sky procedure in a perforated eye may cause intraoperative and postoperative complications , including suprachoroidal hemorrhage and early corneal graft failure.3 therefore , a closed - eye procedure is believed to be safer where perforation has occurred . in addition , when endophthalmitis may have occurred following traumatic injury , the risk of primary graft failure is higher ; and subsequent corneal regrafting also carries a higher risk of graft rejection due to persistent inflammation . in the current case , a favorable surgical outcome with useful vision and transparent corneal graft with no complications or episodes of infection and/or rejection was observed . the intraoperative endoscopic approach adopted here allowed observation of the ciliary sulcus , pars plana , and vitreous base , enabling us to observe an intraocular foreign body in a perforated eye that might have gone undetected otherwise . although the endoscopic view itself is non - stereoscopic , shadows created by intraocular surgical instruments and endoscopic illumination may provide pseudo - stereoscopic images , allowing estimation of the distance between the intraocular surgical instruments and the retina . however , this indirect sensing of space and dimension differs from that achieved with an operating microscope . therefore , greater caution may be required in estimating space and dimension in endoscopic procedures during surgery . where no corneal transplantation is carried out , there may be problems with observing the eye during postoperative follow - up due to corneal opacity . in addition , endoscopic vitrectomy and subsequent keratoplasty have the disadvantage of requiring a longer time for visual rehabilitation to occur while the patient waits to undergo a corneal transplantation . however , this two - step procedure comprising endoscopy - guided vitrectomy followed by corneal transplantation offers a useful option to vitreoretinal surgery with simultaneous penetrating keratoplasty in trauma cases where there is severe penetration of the anterior segment , allowing avoidance of excessive damage to the corneal endothelium and initial graft failure . we described a case of perforating eye injury with corneal opacity and possible endophthalmitis and an intraocular foreign body successfully treated with a two - step procedure comprising endoscopy - guided vitrectomy followed by corneal transplantation .
introduction : severe ocular trauma requires emergency surgery , and a fresh corneal graft may not always be available . 
 we describe a case of perforating eye injury with corneal opacity , suspected endophthalmitis , and an intraocular foreign body . 
 the patient was successfully treated with a two - step procedure comprising endoscopy - guided vitrectomy followed by corneal transplantation . 
 this surgical technique offers a good option to vitrectomy with simultaneous keratoplasty in emergency cases where no graft is immediately available and there is the possibility of infection due to the presence of a foreign body.case presentation : a 55-year - old japanese woman was referred to our hospital with a perforating corneal and lens injury sustained with a muddy ferrous rod . 
 primary corneal sutures and lensectomy were performed immediately . 
 vitreoretinal surgery was required due to suspected endophthalmitis , vitreous hemorrhage , retinal detachment , dialysis and necrosis of the peripheral retina . instead of conventional vitrectomy , 
 endoscopy - guided vitreous surgery was performed with the solid fiber catheter as-611 ( fibertech , tokyo , japan ) due to the presence of corneal opacity and the unavailability of a donor cornea . 
 the retina was successfully attached with the aid of a silicon oil tamponade . following removal of the silicon oil at 3 months after surgery , penetrating keratoplasty and intraocular lens implantation with ciliary sulcus suture fixation 
 were performed . at 6 months after penetrating keratoplasty , the graft remained clear and visual acuity was 20/40.conclusion : primary endoscopic surgery for vitreoretinal complications in eyes with perforating injury performed prior to penetrating keratoplasty appears to be advantageous in terms of avoiding damage to the corneal endothelium .