Conjunctival and Corneal Foreign Object Removal

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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.