Author:

Carl G.Skinner

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

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, positive Seidel test, or hyphema

Diagnostic Tests & Interpretation

Differential Diagnosis

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

Prehospital

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 oral analgesia

Medication

• Cycloplegics:
  • Cyclopentolate 1-2%: 1 drop t.i.d (lasts up to 2 d)
  • Homatropine 2 or 5%: 1 drop daily (lasts up to 3 d)
• Topical antibiotics for 3-5 d: 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

Disposition

Follow-up Recommendations

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

• AhmedF, HouseRJ, FeldmanBH. Corneal abrasions and corneal foreign bodies . Prim Care. 2015;4(3):363-375.
• SweetPH 3rd. Occult intraocular trauma: Evaluation of the eye in an austere environment . J Emerg Med. 2013;44(3):e295-e298.
• WalkerRA, AdhikariS. Eye emergencies. In: TintinalliJE, StapczynskiJ, MaO, et al, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed.New York, NY: McGraw-Hill; 2016.
• WippermanJL, DorschJN. 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

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)