Ocular Foreign Bodies

Runal Shah2nd year Resident,

Masters in Emergency MedicineKDAH

Objectives

i. Basicsii. Clinical Presentationiii. Practical scenarioiv. Treatment modalitiesv. Specialist care

Case

i. 26 year old female, comes to A&E at 10.30 PM, with c/o pain and irritation in left eye x 2 hours

• She doesn’t recollect what went wrong !!

ii. 38 year old male, a bike rider, comes to A&E at 12.45 AM with c/o increased watering from right eye x 30 min, with pain and inability to open same eye

iii. 16 year old male, comes from school with c/o left eye irritation while playing football x 15 min

Basics

Foreign body classificationi. Toxic

– Metallic • Magnetic – iron, steel, nickel • Non magnetic – copper, aluminum, mercury, zinc

– Non-metallic – vegetative matter

ii. Inert– Metallic – Gold, silver, platinum– Non-metallic – Glass, carbon, stone, porcelain, plaster,

rubber

Clinical Presentation

• Corneal FB– Usually Benign and

superficial– If penetration – Globe

rupture and loss of vision– Inflammatory reaction :

dilatation of blood vessels of conjunctiva – edema of lids, conjunctiva and cornea.

– Anterior chamber reaction/ corneal infiltration

• Conjunctival FB– Less painful as less

innervation– If full thickness

penetration – loss of vision

– Signs: mild injection, sub-conjunctival hemorrhage

– Symptoms: scratchy FB sensation, tearing, mild pain, (rarely) photophobia

Practical Scenario

• History of event– Place or location of trauma– High / low velocity– Any immediate intervention taken?

• Examination– Inspection (both eyes!)– Simultaneous irrigation with saline– Watch for small FB particles– Cotton tip – moistened applicator– 25G needle on syringe

Practical Scenario

We don’t have these

Slit Lamp Alger Brush

Examination

Upper lid eversion and conjunctival fornices examination

Treatment Modalities

Moistened Cotton tip applicator 25G needle on syringe

Topical Anesthetic Eye drops

• Proparacaine 0.5% to anesthetize cornea before attempted FB removal.

•Anesthetizing both eyes is helpful, as it eliminates reflex blinking.

Fluorescein eye test• Indications –

– Suspected FB– Abrasions– Infections

• Contra-indications – – Contact lenses– Idiosyncratic reactions

• Ideally to fluoresce in blue light in slit lamp, corneal defect is readily visible.

•Caution: Fluorescein with topical anesthetic can cause punctate keratitis!

Topical antibiotics

Moxifloxacin Ciprofloxacin

Other Antibiotics – • Polymixin-B+Trimethoprim (Polytrim)

• Ofloxacin• Gatifloxacin• Bacitracin• Tobramycin (Tobrex)

Specialist Consultationo Hyphema (blood in anterior chamber)o Diffuse corneal damageo Scleral / corneal lacerationo Lid edemao Diffuse subconjunctival hemorrhageo Posttraumatic pupillary dilatation/ abnormal pupil

shapeo Abnormally shallow/ deep anterior chamber compared

to fellow eyeo Persistent corneal defect / corneal opacityo Possibility of full penetration / sclera

Complications

• Rust ring usually due to an iron FB and can be removed carefully at a slit lamp using a burr (Alger Brush).

• Infectious Keratitis is common in organic injuries and neglected cases. It may need to be scraped for smears and cultures. It needs to be treated aggressively with topical antibiotics.

• Globe perforation occurs in metal-on-metal and similar high speed type injuries. It also can occur if a corneal ulcer is neglected. It requires surgical repair.

Patient Education

• Remind patients of the importance of wearing PROTECTIVE EYE-WEAR in any high risk situation.

• Eyes should not be rubbed while working with wood / metal pieces.

• If a FB enters the eye, the eye should not be rubbed or no attempt should be made by the patient to remove the FB.

Thank you…

References Roberts and Hedges’ Clinical Procedures in Emergency Medicine – 5/e

Rosen's Emergency Medicine 8/e Tintinalli’s Emergency Medicine 7/e

Pictures courtesy : www.medscape.com http://eyewiki.org