Ocular foreign body: Difference between revisions
Line 18: Line 18:
===Intraocular===
===Intraocular===
*As above, although may additionally be asymptomatic initially and present after complications arise (e.g. corneal ulcer)
*As above, although may additionally be asymptomatic initially and present after complications arise (e.g. corneal ulcer)
*+Sidel's sign


==Differential Diagnosis==
==Differential Diagnosis==

Revision as of 12:04, 30 March 2017

Background

  • General approach to trauma from ocular foreign body or foreign body sensation
  • 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

Subacute/Delayed

Unilateral red eye

^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
  • 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

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

  • For Superficial ocular foreign body with no signs of open globe injury
    • ED removal from conjunctiva or cornea after topical anesthetic
      • Copious irrigation
      • Cotton-tipped swab soaked in saline
      • 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
    • Tetanus booster as needed
    • 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

  • Emergent surgical intervention for

See Also

External Links

References

  1. ↑ Babineau MR, Sanchez LD, Ophthalmologic procedures in the emergency department Emerg Med Clin Am 2008 26.1:17-34.
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