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
Foreign Body Types
- Ear foreign body
- Nasal foreign body
- Ocular foreign body
- Aspirated foreign body
- GI
- Soft tissue foreign body
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
- Foreign body 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.