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)

[Outline]

• DESCRIPTION
• ETIOLOGY

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

ALERT

DIFFERENTIAL DIAGNOSIS

• Conjunctival FB
• Corneal abrasion
• Corneal perforation with or without intraocular FB
• Corneal ulcer
• Keratitis

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

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 patient's 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).

Pediatric Considerations

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

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

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

FOLLOW-UP RECOMMENDATIONS

Return or follow-up with a physician if symptoms continue or worsen in 1 or 2 days.

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 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.

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

[Outline]

• ICD9
• ICD10

• 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. Tintinalli's 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)

• Corneal Abrasion
• Red Eye

Ian C. May

Carl G. Skinner