Corneal Foreign Body Removal
What is a “foreign body” of the cornea?
A corneal foreign body is foreign material on or in the cornea. This material usually consists of metal, glass, or organic material. In the environment of today's factories, production facilities, and homes these materials are everywhere.
A corneal foreign body generally falls under the category of minor ocular trauma. Small particles may become lodged in the top layer of the cornea known as the epithelium or stroma, particularly when projected toward the eye with considerable force.
When this foreign body strikes the cornea it may set off an inflammatory cascade, resulting in redness of the surrounding vessels and subsequent swelling of the eyelids, conjunctiva, and cornea. White blood cells also may be liberated, resulting in a painful reaction inside of the eye and/or corneal infiltration.
If not removed, a foreign body can cause infection and/or tissue destruction. Generally, superficial foreign bodies that are removed soon after the injury leave no permanent marks on the eye. However, corneal scarring or infection may occur.
The longer the time interval between the injury and treatment, the greater the likelihood of complications. If the foreign body fully penetrates into the anterior or posterior chambers, then it is officially an intraocular foreign body. In this case, eye disability is much more common. Damage to the iris, lens, and retina can occur and severely damage vision. Any intraocular foreign body can lead to infection and endophthalmitis, a serious condition possibly leading to loss of the eye.
24 Hour Emergency Care for Foreign Body Removal
At Graf Optical Family Eye Care and Glaucoma, we recognize that time is of the essence when addressing and treating a' foreign body. Our doctors have the training and expertise to quickly and effectively manage and treat even the most difficult foreign bodies. Foreign body patients receive immediate treatment and scheduling. No appointment is necessary for these patients.
Rather than make your family members or employees wait for hours in the emergency room, we encourage you to trust your foreign body emergencies to the leaders in medical eye care and foreign body removals
Even late at night Graf Optical is accessible through 24 hour on call emergency services at (651) 206-2418.
Who is most susceptible to have a foreign body?
The group most likely to have a foreign body is young males. Similar to most other traumatic injuries, the peak incidence is found in the second decade and generally occurs in people younger than 40 year.
In the United States foreign bodies are one of the most frequent causes of visits for ophthalmic emergencies. Sometimes, the foreign body may not be present at the time of examination, having left the residual corneal abrasion with resultant pain.
Superficial corneal foreign bodies are much more common than deeply embedded corneal foreign bodies. Eye doctors always consider the possibility of an intraocular foreign body when a patient presents with a history of trauma. .
Foreign Body Treatment at Graf Optical
History:
When a patient comes in with a red eye and the possibility of a foreign body in the eye it is of the utmost importance that a very thorough and complete history be taken. Questions asked by the Graf Optical staff over the phone will find out when the condition started or when it happened. What were the circumstances/conditions surrounding the incident.
a) Were you hit in the eye with something and if so with what?
Were you struck by wood, metal, glass, pizza, etc.; or were you hammering on something if so, on what, with what
b) When did your condition start?
When did you first notice the condition?
c) Did you take anything for the eye pain?
If so what and has it helped?
Have you put anything in your eye, if so what? In other words, have you made an attempt to treat the condition?
If there has been a treatment, what was its nature? With what?
Did you try and put a medication known as Visine into the eye. Visine is a vasoconstrictor, which now makes the eye less red.
d) Was the object moving at a high speed or low speed when it hit the eye?
If the object was a fast moving object there is a greater chance of the object being a penetrating foreign body due to the higher speed of the projectile as opposed to something "falling" in the eye.
2.) Visual Acuities
You may be in a great deal of pain and not able to open your eyes. Even though you are in pain, the eye doctor must obtain some degree of visual acuity. Taking acuity is important, as it is a measure of success in treating the condition and it established a baseline. Essentially, it is important for a pre/post comparison.
3.) Slit Lamp Examination
a) Are the pupils equal in size and do they react equally to light? Small pupil might indicate an inflammation in the front of the eye known as an “anterior uveitis.”
b ) Is there a consensual pain reflex present indicating a smoldering anterior uveitis or an embedded foreign body.
c ) Is there conjunctival injection (redness) or is the injection more limbal in location? What degree of redness are you seeing: slightly red or very bright red? Conjunctival blanching is also an important sign. It might indicate chemical insult to the eye, which has to be ruled out.
d ) Is the anterior chamber clear or are there cells and/or flare present and what grade of cells or flare are you seeing?
e ) Does the iris look normal or does it have a muddy appearance again indicating an anterior uveitis?
f ) What does the cornea look like without stain (sodium fluorescein). NOTE: You should never use Fluress® as the initial anesthetic of choice because the sodium fluorescein will enter the anterior chamber before you have had a chance to evaluate it for cells and flare.
g ) You should now evaluate the cornea and conjunctiva with sodium fluorescein taking note of any staining and its extent and depth. At this point also look very carefully for any percolating fluid from the eye which will look like a dark drainage against the fluorescein green color of the tear film. This is called thepercolation test for a penetrating injury to the eye; and if you notice the waterfall effect described (a.k.a. Seidel's sign), follow the instructions above under HISTORY part (e) and refer the patient.
h ) Everting the upper eye lid:
The eye doctor will evert the upper eye lid and examine the lower lid checking for foreign bodies. If it has been a windy day the patient may have a foreign body located just under the edge of the upper lid which is the most common location (subtarsal fold). You should also pay attention to a very typical foreign body track staining pattern. The foreign bodies located on the palpebral conjunctive can usually be removed with a Q-Tip that has been moistened with saline. If there are any foreign bodies or you suspect their presence due to patient complain, remember that you MUST double evert the lid.
NOTE: Keep in mind that the patient has had to be anesthetized. Remember to educate the patient to tell you if the foreign body sensation returns after your examination (when anesthesia has worn off). This may mean there is more matter left in the eyes.
To double evert, use a paper clip that is bent open to an angle of approximately 90 degrees. Use the paper clip to evert the lid just as you would using a cotton swab, but now because of the angle of the clip while it is partially "sandwiched" between the everted lid and the upper lid skin, you will be able to pull up and back on the exposed end of the clip and look underneath the already everted lid. This technique will be demonstrated to you in class. You may also use a cotton swab for this purpose.
i ) f you find a foreign body lodged in the cornea or conjunctiva your first method to remove it should be to try flushing it out, preferably with a pressurized saline solution. You should first place one or two drops of .5% Proparacaine HCl in the eye before trying to force or blast the foreign body out. Have the patient look in a direction away from you so they will not see the spray of saline coming.
j ) It is extremely important that you document the type and location of foreign body you have removed with a drawing, what was used to remove the foreign body, any post removal procedures, i.e. (removal of rust ring), any and all medications that have been placed in the eye and the amount, the time of day the procedure was performed, and the date and time the patient is to return for a follow up visit. In most cases this will be in less than 24 hours. If the patient fails to show up for his/her appointment, call and document that you called along with the time, date and what the patient said, or whether you were able/unable to leave a message.
k ) Once the foreign body has been removed, if there is an anterior uveitis, you should then instill one or two drops of 5% Homatropine into the eye and always wait to make sure the eye starts to dilate before patching the patient, if indicated (see below). There are very good reasons for using Homatropine over other agents.
First, it helps restore the impermeability to the iris vessels which prevents the release of cells and proteins (flare) into the anterior chamber.
Second, it prevents a posterior synechiae from forming thus preventing the possibility of secondary glaucoma.
Third, it causes cycloplegia thus knocking out the ciliary muscle and preventing ciliary spasms and pain. It makes the patient much more comfortable.
NOTE: In the cases of frank iritis, where there is already some synechiae starting to form, cyclopentolate may be a better agent since it will allow some "rocking" of the iris in response to light and thereby break the adhesions before they become too strong.Important: Don't forget to tell the patient they will not be able to see at near is the cycloplegic medication NOT the red eye.
There are certain conditions that you do not want to patch.
First, patients with a corneal ulcer. Even though you may be using a wide spectrum antibiotic under the patch the cornea has an open infection There are certain microorganisms that antibiotics might not be able to combat. The patch makes for a nice warm dark environment for them in which to grow.
Second, patients who have developed abrasions secondary to soft contact lens over wear. Since, it was the contact lens covering the cornea that caused the problem in the first place it is not prudent to keep the cornea covered again using a patch. Studies have shown that in these cases the corneas healed much faster when not patched. This means the patient should be dilated and medicated, sometimes around the clock depending on the severity of the contact lens induced keratitis. Pressure patching prevents fully medicating the patient and hence is strongly contraindicated. Additionally, the patch will further deprive the cornea from oxygen, which is the main problem to begin with (see below);
Third, chemical burns are also contraindications for patching. The chemical agent may not have been thoroughly lavaged from the eye. Patching will allow extended exposure to the agent under closed lids and is strongly contraindicated.
Important NOTE: Management of corneal abrasion secondary to Soft Lens Associated Corneal Hypoxia (SLACH) may include aggressive antibiotic therapy. If there is no ulcer Tobrex® solution or gentamycin might be indicated during waking hours and an ointment (Polysporin®) for night time protection. Ciloxan and Ocuflox are new agents which have quickly become the standard of care for management of SLACH/ulcer secondary to soft lens wear. In case of an ulcer, particularly if the floor of the ulcer stains indicating an infected lesion, the new standard of care (the old being fortified tobramycin which is still widely used) is fluroquinolones (Ciloxan®). The dosage for an infected ulcer is: One to two drops every 15-30 minutes for the first two hours, then reduce to one drop every two hours AROUND THE CLOCK for the first 24 hours. Then reduce to only during waking hours along with tobramycin or Polysporin® ointment for night time coverage.
ITEM: In many soft lens-related corneal complications, Tobradex must be given serious consideration. This combination agent (tobramycin/dexamethasone) is an antibiotic/steroid preparation, which is very helpful in preventing secondary infections as well as reducing the possibility of infiltrative scarring of the cornea.
If you choose to pressure patch, keeping in mind all the contraindications, it is very important that the pressure patch is applied correctly. You want just enough pressure so as to prevent blinking (the patient should not be able to open the eye under the patch). You want to keep the lid from moving over that cornea and causing discomfort to the patient. If the patch comes loose during the night, it is possible that it will need to be replaced. If the patient is not capable of correctly applying the patch, it is up to the clinician to provide after hour service and re-apply the patch. There is such a thing as too much pressure being applied with a patch. You do not want the patch so tight that it causes the intraocular pressures to rise and cause discomfort to the patient.
Alternative to traditional patching is to use a bandage contact lens. This has the benefit of allowing oxygen to get to the cornea and also it is better tolerated by some patients. Also, the patient is now able to use antibiotic drops during the day over the contact lens for better antibacterial protection. However, in severe abrasions you still must consider pressure patching as you will practice in lab. Therefore, do not think of the contact lens method as a panacea. There are varying opinions on when and how it should be used. Sometimes it is used later in the course of treatment after some abrasion healing has occurred, to reduce corneal edema induced by pressure patching. Most recent clinical trials have, on occasion, RECOMMENDED use of the bandage lens along with pressure patch for added protection.
NOTE: The topic of "to patch or not to patch" is a constantly ongoing battle. Pressure patching continues to fall out of favor. In fact, some advocate NO patch at all even when the cause of abrasion is not among the categories listed above. It is felt that oxygen is the most important need of the cornea and any type of patch will compromise cornea's ability to receive oxygen. The size of the abrasion is also a factor. Pressure patching is now reserved for deep, large abrasions which border on lacerations of the cornea.
Since the patient will be in a great deal of discomfort, particularly early in the course of your treatment, recommend use of over the counter analgesics such as aspirin and/or acetaminophen. These two have a synergistic action, i.e., sum of the parts is GREATER than just an additive effect-- (2+2=8). Remember to ask about aspirin allergy. There will be cross sensitivity to other analgesics. Aspirin is contraindicated in the case of blunt traumas where there is a chance of internal bleeding. Acetaminophen (Tylenol) should not be taken in conjunction with alcohol due to high potential for liver toxicity.
The new analgesic agent, diclofenac, which is an non-steroidal anti-inflammatory drug (NSAID) used in oral form (Cataflam® or Voltaren®), or in some cases, in topical (Voltaren®) form should be used. Diclofenac is a very potent analgesic agent, however it does upset the stomach more than aspirin and it has cross sensitivity reaction with aspirin.
As of Fall of 1999, optometrists are allowed to prescribe a new oral analgesic medication named ULTRAM®, which is not an NSAID. It is classified as an OPIOID and therefore can be prescribed for cases of blunt trauma as it does NOT promote bleeding.
Ultram® is subject to warning regarding sleepiness. It may cause drowsiness and can only prescribed for a period of five days.
