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Corneal Foreign Body, Emergency Medicine

Basics

Description

- 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

- 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

- 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

  • Foreign material on or in the corneal epithelium
  • Corneal epithelium disrupted:Abrasion if only epithelium disruptedScar 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 acuityVisual fieldsExtraocular movementsLids and lashesPupilsScleraConjunctivaAnterior chamberFundi:Slit-lampFluorescein examPerform 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 visualizationHold 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 focusRemove 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 q6hSulfacetamide 10%: 1 drop q6hCiprofloxacin: 1 drop q6hOfloxacin: 1 drop q6hPolymyxin/trimethoprim: 1 drop q6h
  • Topical NSAIDs:Ketorolac: 1 drop q6hDiclofenac: 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 ulcerationAny evidence of infection or ulcerationMultiple FBsIncomplete FB removal
  • Ophthalmology follow-up in 24 hr for:Abrasion in the visual fieldLarge abrasionAbrasions that continue symptomatic or worsen the next dayRust 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)