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
2nd year Resident,
Masters in Emergency Medicine
KDAH

2. Objectives
i. Basics
ii. Clinical Presentation
iii. Practical scenario
iv. Treatment modalities
v. Specialist care

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

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

6. 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

7. 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

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

9. Examination
Upper lid eversion and conjunctival fornices examination

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

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

12. 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!

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

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

15. 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.

16. 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.

17. 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