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
*Blurry Vision
*[[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)
*+Sidel's sign
*+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
****Should have negative Seidel sign (no streaming of fluorescein out of eye)
***[[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
****Should have negative Seidel sign (no streaming of fluorescein out of eye)
***[[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
*[[Tetanus]] booster as needed
*Pain control with topical [[NSAIDs]] (e.g. [[diclofenac]] or [[ketorolac]]) or oral [[opioids]]
*[[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===
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***Cotton-tipped swab soaked in saline
***Cotton-tipped swab soaked in saline
*Rust ring
*Rust ring
**Not a true emergency as many will wash out spontaneously
**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
**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]]
*[[Corneal foreign body]]
**ED removal after topical anesthetic  
**ED removal after topical anesthetic  
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**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 [[cycloplegics]] (e.g. [[cyclopentolate]] or [[homatropine]]) for significant photophobia
**Consider [[cycloplegic]]s (e.g. [[cyclopentolate]] or [[homatropine]]) for significant 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)
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*Prophylactic empiric [[antibiotics]]
*Prophylactic empiric [[antibiotics]]
*Placement of rigid eye shield
*Placement of rigid eye shield
*Analgesia (oral [[NSAIDS]] or [[opioids]]) and [[antiemetics]] as necessary
*[[Analgesia]] (oral [[NSAIDS]] or [[opioids]]) and [[antiemetics]] as necessary


==Disposition==
==Disposition==
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*Superficial ocular foreign body after removal
*Superficial ocular foreign body after removal
**Ophtho follow up in 48h for routine cases
**Ophtho follow up in 48h for routine cases
**Ophtho follow up in 24h for rust ring removal
**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==
*[[Corneal foreign body]]
*[[Conjunctival abrasion]]
*[[Corneal abrasion]]
*[[Corneal abrasion]]
*[[Corneal ulcer]]
*[[Eye Algorithms (Main)]]
*[[Eye Algorithms (Main)]]
*[[Corneal Ulcer]]
*[[Conjunctival Abrasion]]
*[[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

A small piece of iron lodged near corneal margin.
  • 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)

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

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)
  • Non-high impact metal history (vegetation, dirt, dust)

Contraindicated

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
  • 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

Does Not Wear Contact Lens

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

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:

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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