Basics
Description
- Foreign material on or in the corneal epithelium
- Corneal epithelium disrupted:
- Abrasion if only epithelium disrupted
- Scar if deeper layers of cornea involved
Etiology
- Foreign material causes inflammatory reaction:
- May develop conjunctivitis, corneal edema, iritis, necrosis
- Poorly tolerated:
- Organic material (plant material, insect parts)
- Inorganic material that oxidizes (iron, copper)
- Well tolerated:
- Inert objects (paint, glass, plastic, fiberglass, nonoxidizing metals)
Diagnosis
Signs and Symptoms
- Foreign body (FB) sensation
- Eye pain
- Conjunctiva and sclera injection
- Tearing
- Blurred or decreased vision
- Photophobia
- Visible FB or rust ring
- Iritis
History
Common complaint: Something fell, flew, or otherwise landed in my eye:
- Hot, high-speed projectiles may not produce pain initially.
Physical Exam
- Complete eye exam:
- Visual acuity
- Visual fields
- Extraocular movements
- Lids and lashes
- Pupils
- Sclera
- Conjunctiva
- Anterior chamber
- Fundi:
- Slit-lamp
- Fluorescein exam
- Perform Seidel test (visualization of flow of aqueous through corneal perforation during fluorescein slit-lamp exam)
- Intraocular pressure if no evidence of perforation
Essential Workup
- Injury history to determine type of FB and likelihood of perforation
- Exclude intraocular FB:
- Suspect intraocular FB with high-speed mechanisms, such as machine operated or hammering metal on metal, or positive Seidel test.
Diagnosis Tests & Interpretation
Imaging
- Orbital CT scan or B-mode US when suspect intraocular FB
- Orbital plain radiograph to screen for intraocular metallic FB
Avoid MRI for possible metallic FBs.
Differential Diagnosis
- Conjunctival FB
- Corneal abrasion
- Corneal perforation with or without intraocular FB
- Corneal ulcer
- Keratitis
Treatment
Pre-Hospital
Place a Fox shield and position the patient upright.
Initial Stabilization/Therapy
Apply topical anesthetic to stop eye discomfort and assist in exam.
Ed Treatment/Procedures
- Deep FBs:
- Refer those penetrating the Bowman membrane (next layer under epithelium) to an ophthalmologist, because permanent scarring may occur.
- Superficial FBs:
- Irrigation removal technique
- Apply topical anesthetic
- Try to wash FB off cornea by directing a stream of 0.9% NS at an oblique angle to cornea:
- 25G needle or FB spud removal technique:
- Using slit-lamp to immobilize patients head and allow good visualization
- Hold needle (bevel up) with thumb and forefinger, allowing other fingers to be stabilized on the patient's cheek.
- Lift FB off cornea, keeping needle parallel to corneal surface.
- Rust rings removal:
- Within 3 hr, iron-containing FBs oxidize, leaving a rust stain on adjacent epithelial cells.
- Removal recommended as rust rings delay healing and act as an irritant focus
- Remove with needle or pothook burr either at same time as FB or delayed 24 hr
- Postremoval therapy:
- Recheck Seidel test to exclude corneal perforation.
- Treat resultant corneal abrasion with antibiotic drops or ointment.
- Initiate cycloplegic agent when suspect presence of keratitis.
- Update tetanus.
- Initiate analgesia (nonsteroidal anti-inflammatory drug [NSAID] or acetaminophen with oxycodone).
May require sedation to facilitate exam and FB removal
Medication
- Cycloplegics:
- Cyclopentolate 1-2%: 1 drop TID (lasts up to 2 days)
- Homatropine 2% or 5%: 1 drop daily (lasts up to 3 days)
- Topical antibiotics for 3 to 5 days: Often used but unproven benefit:
- Erythromycin ointment: Thin strip q6h
- Sulfacetamide 10%: 1 drop q6h
- Ciprofloxacin: 1 drop q6h
- Ofloxacin: 1 drop q6h
- Polymyxin/trimethoprim: 1 drop q6h
- Topical NSAIDs:
- Ketorolac: 1 drop q6h
- Diclofenac: 1 drop q6h
Follow-Up
Disposition
Admission Criteria
Globe penetration
Discharge Criteria
All corneal FBs
Issues for Referral
- Consult ophthalmologist for:
- Vegetative material removal owing to risk of ulceration
- Any evidence of infection or ulceration
- Multiple FBs
- Incomplete FB removal
- Ophthalmology follow-up in 24 hr for:
- Abrasion in the visual field
- Large abrasion
- Abrasions that continue symptomatic or worsen the next day
- Rust ring removal
Followup Recommendations
Return or follow-up with a physician if symptoms continue or worsen in 1 or 2 days.
Pearls and Pitfalls
- Consider intraocular FB, especially with history of high-projectile objects or industrial tools.
- Clinical evidence does not support eye patching for pain or healing.
- After removal, most corneal FBs can be treated as an abrasion and usually do well without further treatment.
- Topical anesthetics should not be prescribed for home use.
Additional Reading
- Ramakrishnan T, Constantinou M, Jhanji V, et al. Corneal metallic foreign body injuries due to suboptimal ocular protection. Arch Environ Occup Health. 2012;67(1):48-50.
- Reddy SC. Superglue injuries of the eye. Int J Ophthalmol. 2012;5(5):634-637.
- Sweet PH 3rd. Occult intraocular trauma: Evaluation of the eye in an austere environment. J Emerg Med. 2013;44(3):e295-e298.
- Walker RA, Adhikari S. Eye emergencies. In: Tintinalli JE, ed. Tintinallis Emergency Medicine: A comprehensive Study Guide. 7th ed. 2011:1517-1549.
- Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.
See Also (Topic, Algorithm, Electronic Media Element)
Codes
ICD9
930.0 Corneal foreign body
ICD10
- T15.00XA Foreign body in cornea, unspecified eye, initial encounter
- T15.01XA Foreign body in cornea, right eye, initial encounter
- T15.02XA Foreign body in cornea, left eye, initial encounter
SNOMED
- 37450000 Corneal foreign body
- 231942005 Corneal rust ring (disorder)
- 287127003 Splinter in cornea (disorder)