Introduction
Conjunctival and corneal foreign objects
are commonly seen problems in the primary care office and in the
emergency department. Removal of the foreign object is usually easy
accomplished and can be performed in the outpatient setting. When a
patient presents, document a thorough history including job type, the
condition of the eye before injury, probable type of foreign body
(especially if it may be iron based), mechanism of injury, and whether
first aid was rendered. Always test and document the patient 's
vision before and after treatment. Use a Snellen chart or an equivalent
visual acuity chart if possible.
View OriginalView Original
Because of the risk of complications,
obtaining informed consent is a necessity prior to treatment. Possible
complications of foreign body removal include infection, incomplete
removal of a foreign body, perforation of the cornea, scarring, and
permanent visual impairment. Special care must be taken with iron-based
foreign objects, because rust is toxic to the cornea and may prevent it
from healing.
The corneal and conjunctival epithelia
are some of the fastest-healing areas of the body. If considerable
progress toward healing has not been made within 24 hours of foreign
body extraction, re-examine for additional foreign bodies or signs of
infection. Pain may be an important indicator of developing corneal
ulceration or the presence of an additional foreign body. Therefore,
local anesthetic drops and topical steroids should not be prescribed for
outpatient use. The other reasons to avoid local anesthetic drops are
because they may retard corneal healing and might lead to corneal
perforation. They are often used during mechanical removal of foreign
objects in the clinical setting only.
If the patient has significant pain,
consider using a cycloplegic agent to decrease spasm of the iris. Apply
antibiotic drops or ointment for prophylaxis. An ointment may be better
than drops because of its lubricant effect and ability to help reduce
disruption of the newly generated epithelium. Oral pain medication
should be prescribed as indicated. Instruct the patient not to rub the
eye, because it may disrupt the new epithelial layers of the cornea.
Traditionally, eye patches were applied,
on the theory that they decreased photophobia, tearing, foreign body
sensation, pain, and healing time. However, studies indicate that
patching does not improve pain scores, healing times, or treatment
outcomes. It may also decrease patient compliance with treatment
plans.
Clinicians must use extreme caution when
attempting to remove foreign objects by mechanical means such as
cotton-tipped applicators or needles. Object removal is most successful
in cases of recent, superficial foreign bodies. Any downward pressure on
the object may result in more damage to the epithelium or deeper layers.
If clinicians are unsure of their ability to remove an object without
exerting downward pressure on it, the patient should be referred to an
ophthalmologist for removal.
Re-epithelialization is complete in 3 to
4 days for more than 90% of patients, but it can take weeks.
Re-examine every 24 hours until the eye is healed. Perform and document
a visual acuity test on the last visit. Continue antibiotic drops or
ointment for an additional 3 days after the eye is free of symptoms. The
patient may be unusually receptive at this time to education about eye
safety measures such as protective eyewear. If the pain increases at any
time during the follow-up or signs of conjunctival or orbital infection
are seen, immediately refer the patient to an ophthalmologist.
It is important to know when to refer
patients to an ophthalmologist to decrease the risk of impaired vision
or blindness. Indications for immediate referral include an intraocular
presence of an object, a large corneal epithelial defect, a corneal
infiltrate or white spot, corneal opacity, or a purulent discharge. The
patient should also be referred to an ophthalmologist immediately for
any chemical injury, or if pain or functional impairment persists after
irrigation. Possible acid or alkali contamination of the eye is a true
ophthalmologic emergency.
Equipment
- A Snellen chart or
equivalent visual acuity chart can be obtained from Premier
Medical, P. O. Box 4132, Kent, WA 98032. Phone: 1-800-955-2774.
Web site: http://premieremedical.safeshopper.com - Medications: topical
ophthalmic anesthetic (e.g., tetracaine [Pontocaine] or
proparacaine [Opthetic]), cycloplegic drops, topical antibiotics
ointment (e.g., erythromycin [Ilotycin], bacitracin, or sulfacetamide). - Magnification devices,
loupes, and Wood 's lights may be ordered from medical
supply companies. Fluorescein strips may be ordered from
pharmacies. - Other materials:
cotton-tipped swabs, hypodermic needle (26 gauge), sterile
water, bag of normal saline with IV drip tubing,
ophthalmoscope.
Indications
- Small, conjunctival, or
corneal foreign bodies embedded <24 hours
Contraindications
- Foreign bodies embedded
in the cornea for >24 hours (i.e., risk of infection) - Iron-based foreign
bodies, which may cause a rust ring (relative
contraindication) - Uncooperative patient
- Deeply or centrally
embedded foreign bodies (i.e., ophthalmologic referral) - Possible acid or alkali
contamination of the eye (i.e., ophthalmologic emergency) - Ruptured globe (i.e.,
ophthalmologic emergency) - Hyphema, lens
opacification, abnormal anterior chamber examination, or
irregularity of the pupil (i.e., possible ruptured globe, which
is an ophthalmologic emergency) - Signs or symptoms of
infection (i.e., ophthalmologic referral)
The Procedure
Step 1
Check and record the
patient 's visual acuity using a Snellen chart.
Step 1 View Original Step 1 View Original
Step 2
Position the patient in the
supine position. For corneal foreign bodies, position the
patient 's head so that the foreign body and the eye are in
the most elevated position. For conjunctival foreign bodies,
position the head to give the examiner maximal access to the
affected area.
Step 2 View Original Step 2 View Original
Step 3
Hold the patient 's
eyelids apart with your thumb and index finger of the nondominant
hand. Ask the patient to fix and maintain his or her gaze on a
distant object and to hold the head as motionless as possible
throughout the procedure.
- PEARL: A wire eye speculum may be used but
usually is not available in primary care offices.
Step 3 View Original Step 3 View Original
Step 4
If a foreign body under the
lid is suspected, evert the eyelid by placing the cotton-tipped swab
on top of the lid and roll the lid over the swab.
- PITFALL: Vertical scratches on the cornea
may indicate a foreign body embedded in the upper lid,
necessitating eyelid eversion and examination with a
cotton-tipped applicator.
Step 4 View Original Step 4 View Original
Step 5
If the object is not readily
visible, put two drops of topical anesthetic into the retracted
lower eyelid while the patient gazes in an upward direction. Wet a
fluorescein strip with the same solution. Apply the fluorescein
strip to the underside of the lower eyelid.
Step 5 View Original Step 5 View Original
Step 6
Inspect the cornea under a
Wood 's light for dye pooling near objects or abrasions that
may help identify the location of a foreign body or demonstrate an
abrasion.
- PITFALL: Putting drops directly on a
scratched cornea can be very painful.
Step 6 View Original Step 6 View Original
Step 7
Attempt to wash out the
object using sterile normal saline or an ophthalmic irrigant. This
may be done by pouring a small, continuous volume of fluid into the
affected eye. An alternative method is to place an intravenous bag
of normal saline with tubing on a pole, cut off the end of the
tubing, and use the gentle stream coming from the end of the tubing
to irrigate the eye.
Step 7 View Original Step 7 View Original
Step 8
If this is unsuccessful,
attempt to dislodge the object using a cotton-tipped applicator or
corner of a soft cotton gauze. Moisten the cotton with local
anesthetic, and gently lift the object by lightly touching it.
- PITFALL: Never use force or rub the cornea
because this can produce pain, damage the epithelium, and
cause deeper corneal injuries.
Step 8 View Original Step 8 View Original
Step 9
If the object is still
lodged, a sterile needle may be used to remove the object. Place a
26-gauge needle on a tuberculin syringe and hold it in with a pencil
grip. Stabilize your operating hand on the patient 's brow or
zygomatic arch. Approach the object with the needle bevel upward
from a tangential direction.
Step 9 View Original Step 9 View Original
Step 10
Use the needle tip to gently
lift the object. Turn the patient 's head laterally, and
copiously irrigate the eye. Retest and record the patient 's
visual acuity.
- PITFALL: If the object cannot be readily
removed, refer the patient for removal under slit lamp by an
ophthalmologist. - PITFALL: If any residual corneal rust is
found, immediately refer the patient to an ophthalmologist
because rust is toxic to the corneal epithelium.
Step 10 View Original Step 10 View Original
Complications
- Infection
- Perforation of the
cornea - Scarring
- Visual impairment
- Corneal ulceration
Pediatric Considerations
The history is less specific, because
the child might not be able to describe the symptoms or the mechanism of
the injury. Any time a child cannot or refuses to open an eye,
penetrating trauma must be ruled out. After that, an attempt to measure
visual acuity with an age-appropriate technique is recommended. Topical
ophthalmic anesthetic can be used to facilitate the examination, which
is similar to that in an adult. Warn the child and the parents that the
anesthetic will cause a burning sensation at first.
Postprocedure Instructions
For small abrasions (<3 mm), no
follow-up is necessary if the patient 's vision is good.
Contact-lens-related abrasions required daily follow-up until the
abrasion is healed to avoid ulceration. Large abrasions (>3 mm)
with a symptom of decreasing vision require close follow-up.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 65205 Removal of foreign body, external eye, conjunctivally
superficial $161.00 0 65210 Removal of foreign body, external eye, conjunctivally
embedded $207.00 0 65220 Removal of foreign body, external eye, corneal without slit
lamp $196.00 0 65222 Removal of foreign body, corneal with slit lamp $248.00 0 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
All of the necessary supplies can be
obtained from hospital supply houses or pharmacies.
Bibliography
1Appen RE, Hutson CE.
Traumatic injuries: office treatment of eye
injury, 1: injury due to foreign materials.
Postgrad Med.
1976;60:223 " 225,
237. 2Gumus K, Karakucuks Mirza
E.Corneal
injury from a metallic foreign body " an occupational
hazard. Eye Contact
Lens.
2007;33(5):259 " 260. [View Abstract] 3Holt GR, Holt JE.
Management of orbital trauma and foreign
bodies. Otolaryngol Clin
North Am.
1988;21:35 " 52. [View Abstract] 4Kaiser PK.
A comparison of pressure patching versus no
patching for corneal abrasions due to trauma or foreign body
removal: Corneal Abrasion Patching Study
Group.
Ophthalmology.
1995;102:1936 " 1942. [View Abstract] 5Le
Sage N, Verreault R, Rochette L.
Efficacy of eye patching for traumatic
corneal abrasions: a controlled clinical
trial. Ann Emerg
Med. 2001;38:129 " 134. 6Nayeen N, Stansfield D.
Management of corneal foreign bodies in
A&E departments. Arch
Emerg
Med. 1992;9:257. [View Abstract] 7Newell SW.
Management of corneal foreign
bodies. Am Fam
Physician. 1985;31:149 " 156. [View Abstract] 8Owens JK, Scibilia J, Hezoucky N.
Corneal foreign bodies " first aid,
treatment, and outcomes: skills review for an occupational
health setting. AAOHN
J.
2001;49:226 " 230. [View Abstract] 9Peate WF.
Work related eye injuries and
illnesses. Am Fam
Physician.
2007;75:7. 10Reich JA.
Removal of corneal foreign
bodies. Aust Fam
Physician.
1990;19:719 " 721. [View Abstract] 11Stout A.
Corneal abrasion.
Pediatric Rev.
2006;27:11. 122008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.