Ocular foreign body: Difference between revisions
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*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. | *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 | *Always consider possibility of multiple foreign bodies | ||
*Common materials based on inflammatory reactions | |||
**Highest inflammatory response - wood, copper, iron, steel | |||
**Moderate reaction - aluminum, mercury, nickel, zinc | |||
**Inert - glass, lead, plastic, porcelain | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Foreign body in eye.jpg|thumb|A small piece of iron lodged near corneal margin.]] | |||
*Patient history with focus on circumstances/mechanism of symptom onset | *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 | **e.g. use of power tools, projectile weapons, MVCs, metal-on-metal impacts, or high-impact trauma | ||
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===Superficial (embedded in conjunctiva or cornea)=== | ===Superficial (embedded in conjunctiva or cornea)=== | ||
*Eye pain | *[[Eye pain]] | ||
*Foreign body sensation | *Foreign body sensation | ||
*Tearing | *Tearing | ||
* | *[[Blurred vision]] | ||
*Relief of pain with topical anesthesia | |||
===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) | ||
*+ | *+Seidel's sign: streaming of fluorescein out of eye | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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**Eye exam | **Eye exam | ||
***[[Slit lamp exam]] with fluorescein | ***[[Slit lamp exam]] with fluorescein | ||
***Intraocular pressure | ***[[Intraocular pressure]] | ||
***Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies | ***Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies | ||
**CT orbit | **CT orbit | ||
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**Eye exam only | **Eye exam only | ||
***[[Slit lamp exam]] with fluorescein | ***[[Slit lamp exam]] with fluorescein | ||
***Intraocular pressure | ***[[Intraocular pressure]] | ||
***Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies | ***Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies | ||
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==Management== | ==Management== | ||
*[[Tetanus]] booster as needed | |||
*[[Analgesia|Pain control]] with topical [[NSAIDs]] (e.g. [[diclofenac]] or [[ketorolac]]) or oral [[opioids]] | |||
===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 | |||
*Rust ring | |||
**Metallic foreign bodies can create rust rings that are toxic to corneal tissue | |||
**May be removed with a 30- to 25-gauge needle as below | |||
**Rust rings overlying the visual axis, however, should be managed by an ophthalmologist due to the risk of scarring in the visual field. | |||
**Rust also often reaccumulates by the next day requiring additional burring. It is therefore not necessary to remove a rust ring in the emergency department if the patient can be seen by an ophthalmologist the next day. Additionally, once the foreign body is removed, the rust ring area softens overnight and can be more easily removed in the office the next day. | |||
*[[Corneal foreign body]] | |||
**ED removal after topical anesthetic | |||
**May attempt irrigation and/or cotton-swab as above | |||
**30- to 25-gauge needle under [[slit lamp]] | **30- to 25-gauge needle under [[slit lamp]] | ||
***Approach from tangential angle | |||
**Repeat Seidel test to ensure removal did not perforate cornea | **Repeat Seidel test to ensure removal did not perforate cornea | ||
**Irrigate eye profusely post-removal | **Irrigate eye profusely post-removal | ||
* | **Consider [[cycloplegic]]s (e.g. [[cyclopentolate]] or [[homatropine]]) for significant photophobia | ||
*[[ | **Consider topical antibiotics for corneal involvement | ||
* | ***Target [[gram-positive]] + [[pseudomonas]] (contact wearers) | ||
*Consider topical antibiotics for corneal involvement | ***[[Moxifloxacin]] – best ophthalmologic penetration | ||
**Target gram-positive + pseudomonas (contact wearers) | |||
**[[Moxifloxacin]] – best ophthalmologic penetration | {{Corneal Abrasion Antibiotics}} | ||
===Intraocular foreign bodies or concern for open globe injury=== | ===Intraocular foreign bodies or concern for open globe injury=== | ||
*Emergent ophthalmology consult | *Emergent ophthalmology consult | ||
*Prophylactic empiric antibiotics | *Prophylactic empiric [[antibiotics]] | ||
*Placement of rigid eye shield | *Placement of rigid eye shield | ||
*Analgesia (oral | *[[Analgesia]] (oral [[NSAIDS]] or [[opioids]]) and [[antiemetics]] as necessary | ||
==Disposition== | ==Disposition== | ||
===Outpatient=== | ===Outpatient Ophthalmology Follow-up=== | ||
*Superficial ocular foreign body after removal | *Superficial ocular foreign body after removal | ||
**Ophtho follow up in 48h for routine cases | |||
**Ophtho follow up in 24h for rust ring removal (rust ring will migrate more and more superficially over time making later removal by ophtho easier) | |||
===Admission=== | ===Admission=== | ||
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==See Also== | ==See Also== | ||
*[[ | *[[Conjunctival abrasion]] | ||
*[[Corneal abrasion]] | *[[Corneal abrasion]] | ||
*[[Corneal ulcer]] | |||
*[[Eye Algorithms (Main)]] | *[[Eye Algorithms (Main)]] | ||
*[[Foreign bodies]] | *[[Foreign bodies]] | ||
==External Links== | ==External Links== | ||
==References== | ==References== |
Revision as of 15:08, 20 October 2019
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
- Common materials based on inflammatory reactions
- Highest inflammatory response - wood, copper, iron, steel
- Moderate reaction - aluminum, mercury, nickel, zinc
- Inert - glass, lead, plastic, porcelain
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
- Blurred vision
- Relief of pain with topical anesthesia
Intraocular
- As above, although may additionally be asymptomatic initially and present after complications arise (e.g. corneal ulcer)
- +Seidel's sign: streaming of fluorescein out of eye
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
- Tetanus booster as needed
- Pain control with topical NSAIDs (e.g. diclofenac or ketorolac) or oral opioids
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
- ED removal after topical anesthetic
- Rust ring
- Metallic foreign bodies can create rust rings that are toxic to corneal tissue
- May be removed with a 30- to 25-gauge needle as below
- Rust rings overlying the visual axis, however, should be managed by an ophthalmologist due to the risk of scarring in the visual field.
- Rust also often reaccumulates by the next day requiring additional burring. It is therefore not necessary to remove a rust ring in the emergency department if the patient can be seen by an ophthalmologist the next day. Additionally, once the foreign body is removed, the rust ring area softens overnight and can be more easily removed in the office the next day.
- Corneal foreign body
- ED removal after topical anesthetic
- May attempt irrigation and/or cotton-swab as above
- 30- to 25-gauge needle under slit lamp
- Approach from tangential angle
- Repeat Seidel test to ensure removal did not perforate cornea
- Irrigate eye profusely post-removal
- Consider cycloplegics (e.g. cyclopentolate or homatropine) for significant photophobia
- Consider topical antibiotics for corneal involvement
- Target gram-positive + pseudomonas (contact wearers)
- Moxifloxacin – best ophthalmologic penetration
Does Not Wear Contact Lens
- Erythromycin ointment qid x 3-5d OR
- Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR
- Ofloxacin 0.3% solution 2 drops q6 hours OR
- Sulfacetamide 10% ophthalmic ointment q6 hours
Wears Contact Lens
Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones
- Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
- Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
- Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Gentamicin 0.3% solution 2 drops six times for 5 days
Intraocular foreign bodies or concern for open globe injury
- Emergent ophthalmology consult
- Prophylactic empiric antibiotics
- Placement of rigid eye shield
- Analgesia (oral NSAIDS or opioids) and antiemetics as necessary
Disposition
Outpatient Ophthalmology Follow-up
- Superficial ocular foreign body after removal
- Ophtho follow up in 48h for routine cases
- Ophtho follow up in 24h for rust ring removal (rust ring will migrate more and more superficially over time making later removal by ophtho easier)
Admission
- With emergent surgical intervention for:
- Intraocular foreign body
- Evidence of open globe
See Also
External Links
References
- ↑ Babineau MR, Sanchez LD, Ophthalmologic procedures in the emergency department Emerg Med Clin Am 2008 26.1:17-34.