Traumatic Pencil Injury With Asymptomatic Intrastromal and Anterior Chamber Deposits

Purpose: To describe a case of asymptomatic corneal and anterior chamber pencil core deposits resulting from a penetrating ocular pencil injury with microbiological and trace element analysis of wooden and mechanical pencils to help guide clinical decisions in similar situations. Methods: This is a case report with culturing of a pencil similar to the one that struck our patient and mass spectrometry analysis of wooden and mechanical pencil cores for elements known to cause ocular toxicity. Results: A 16-year-old boy presented 10 days after being struck with a wooden pencil with an elevated self-sealed corneal laceration, causing irregular astigmatism, with fragments of pencil core deposited in the corneal stroma and anterior chamber. He did not have an anterior chamber reaction or posterior segment injury. Over the next 6 months, his scar flattened and lightened, with normalization of his corneal tomography. A similar pencil grew Enterococcus casseliflavus —an organism well suited to dry environments. Trace elements of pencil core material found the highest concentration of aluminum and iron in wooden pencils, with minimal measured trace elements in mechanical pencils. Conclusions: Retained pencil core material need not always be removed. However, these patients are at risk for infectious and inflammatory sequela, and should be followed closely, with removal of pencil material guided by clinical judgement.