Ocular foreign body

(Redirected from Corneal foreign body)

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)

  • Eye pain
  • Foreign body sensation
  • Tearing
  • Blurry 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)
  • +Sidel'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)
    • 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

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
    • Not a true emergency as many will wash out spontaneously
    • May be removed with a 30- to 25-gauge needle as below
  • 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.