Ocular foreign body: Difference between revisions
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==Management== | ==Management== | ||
===Superficial ocular foreign body with no signs of open globe injury=== | ===Superficial ocular foreign body with no signs of open globe injury=== | ||
*ED removal | *Conjunctival foreign body | ||
**Copious irrigation | **ED removal after topical anesthetic | ||
**Cotton-tipped swab soaked in saline | ***Copious irrigation | ||
***Cotton-tipped swab soaked in saline | |||
**Pain control with topical [[NSAIDs]] (e.g. [[diclofenac]] or [[ketorolac]]) or oral [[opioids]] | |||
**Consider [[Cycloplegics]] (e.g. [[cyclopentolate]] or [[homatropine]]) for photophobia | |||
**[[Tetanus]] booster as needed | |||
**Consider topical antibiotics for corneal involvement | |||
*[[Corneal foreign body]] | |||
**30- to 25-gauge needle under [[slit lamp]] | **30- to 25-gauge needle under [[slit lamp]] | ||
**Repeat Seidel test to ensure removal did not perforate cornea | **Repeat Seidel test to ensure removal did not perforate cornea | ||
| Line 50: | Line 57: | ||
*Pain control with topical [[NSAIDs]] (e.g. [[diclofenac]] or [[ketorolac]]) or oral [[opioids]] | *Pain control with topical [[NSAIDs]] (e.g. [[diclofenac]] or [[ketorolac]]) or oral [[opioids]] | ||
*[[Cycloplegics]] (e.g. [[cyclopentolate]] or [[homatropine]]) for photophobia | *[[Cycloplegics]] (e.g. [[cyclopentolate]] or [[homatropine]]) for photophobia | ||
*Consider topical antibiotics for corneal involvement | *Consider topical antibiotics for corneal involvement | ||
**Target gram-positive + pseudomonas (contact wearers) | **Target gram-positive + pseudomonas (contact wearers) | ||
Revision as of 12:20, 30 March 2017
Background
- Ocular foreign bodies are a high-risk chief complaint because of short and long-term threats to vision loss. The main goal is to determine superficial vs. intraocular foreign bodies.
- Always consider possibility of multiple foreign bodies
Clinical Features
- Patient history with focus on circumstances/mechanism of symptom onset
- e.g. use of power tools, projectile weapons, MVCs, metal-on-metal impacts, or high-impact trauma
- Most common is metal foreign body from hammering
Superficial (embedded in conjunctiva or cornea)
- Eye pain
- Foreign body sensation
- Tearing
- Blurry Vision
Intraocular
- As above, although may additionally be asymptomatic initially and present after complications arise (e.g. corneal ulcer)
- +Sidel's sign
Differential Diagnosis
Orbital trauma
Acute
- Caustic keratoconjunctivitis^^
- Conjunctival hemorrhage
- Conjunctival laceration
- Corneal abrasion, Corneal laceration
- Globe rupture^
- Iridodialysis
- Lens dislocation
- Ocular foreign body
- Orbital fracture
- Frontal sinus fracture
- Naso-ethmoid fracture
- Inferior orbial wall fracture
- Medial orbital wall fracture
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage/hematoma
- Subconjunctival hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
Subacute/Delayed
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Evaluation
Based on patient mechanism/history
- Possible high impact metal (e.g. hammering, use power tools, projectile weapons, metal-on-metal impacts, or high-impact trauma)
- Eye exam
- Slit lamp exam with fluorescein
- Intraocular pressure
- Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies
- CT orbit
- Eye exam
- Non-high impact metal history (vegetation, dirt, dust)
- Eye exam only
- Slit lamp exam with fluorescein
- Intraocular pressure
- Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies
- Eye exam only
Contraindicated
- Ocular ultrasound in setting of open globe injury
- Plain films only detect 40% of IOFB (intra-ocular foreign bodies), so generally not obtained[1]
Management
Superficial ocular foreign body with no signs of open globe injury
- Conjunctival foreign body
- ED removal after topical anesthetic
- Copious irrigation
- Cotton-tipped swab soaked in saline
- Pain control with topical NSAIDs (e.g. diclofenac or ketorolac) or oral opioids
- Consider Cycloplegics (e.g. cyclopentolate or homatropine) for photophobia
- Tetanus booster as needed
- Consider topical antibiotics for corneal involvement
- ED removal after topical anesthetic
- Corneal foreign body
- 30- to 25-gauge needle under slit lamp
- Repeat Seidel test to ensure removal did not perforate cornea
- Irrigate eye profusely post-removal
- Pain control with topical NSAIDs (e.g. diclofenac or ketorolac) or oral opioids
- Cycloplegics (e.g. cyclopentolate or homatropine) for photophobia
- Consider topical antibiotics for corneal involvement
- Target gram-positive + pseudomonas (contact wearers)
- Moxifloxacin – best ophthalmologic penetration
- Schedule follow-up with ophthalmologist
Intraocular foreign bodies or concern for open globe injury
- Emergent ophthalmology consult
- Prophylactic empiric antibiotics
- Placement of rigid eye shield
- Analgesia (oral and topical NSAIDS or opioids) and antiemetics as necessary
Rust rings
- Not a true emergency as many will wash out spontaneously
- May be removed with a 30- to 25-gauge needle as above
Disposition
Outpatient
- Superficial ocular foreign body after removal
Admission
- With emergent surgical intervention for:
- Intraocular foreign body
- Evidence of open globe
See Also
- Corneal foreign body
- Corneal abrasion
- Eye Algorithms (Main)
- Corneal Ulcer
- Conjunctival Abrasion
- Foreign bodies
External Links
References
- ↑ Babineau MR, Sanchez LD, Ophthalmologic procedures in the emergency department Emerg Med Clin Am 2008 26.1:17-34.