Ocular Foreign Body

The most common presenting complaint of Ophthalmology in Emergency dept. is Foreign body sensation, so just to recall the basics of Ophthalm in ED, read the following PPT.

1. Ocular Foreign Bodies Runal Shah 2 nd year Resident, Masters in Emergency Medicine KDAH

2. Objectives Basics Clinical Presentation Practical scenario Treatment modalities Specialist care

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

4. Basics Foreign body classification Toxic Metallic Magnetic – iron, steel, nickel Non magnetic – copper, aluminum, mercury, zinc Non-metallic – vegetative matter Inert Metallic – Gold, silver, platinum Non-metallic – Glass, carbon, stone, porcelain, plaster, rubber

5. 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

6. 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

7. Practical Scenario We don’t have these Slit Lamp Alger Brush

8. Examination Upper lid eversion and conjunctival fornices examination

9. Treatment Modalities Moistened Cotton tip applicator 25G needle on syringe

10. Topical Anesthetic Eye drops Proparacaine 0.5% to anesthetize cornea before attempted FB removal. Anesthetizing both eyes is helpful, as it eliminates reflex blinking.

11. 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!

12. Topical antibiotics Moxifloxacin Ciprofloxacin Other Antibiotics – Polymixin-B+Trimethoprim (Polytrim) Ofloxacin Gatifloxacin Bacitracin Tobramycin (Tobrex)

13. Specialist Consultation Hyphema (blood in anterior chamber) Diffuse corneal damage Scleral / corneal laceration Lid edema Diffuse subconjunctival hemorrhage Posttraumatic pupillary dilatation/ abnormal pupil shape Abnormally shallow/ deep anterior chamber compared to fellow eye Persistent corneal defect / corneal opacity Possibility of full penetration / sclera

14. 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.

15. 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.

16. 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