Ocular foreign body

Background

• Ocular foreign bodies are a high-risk chief complaint because of short and long-term threats to vision loss. The main goal is to determine superficial vs. intraocular foreign bodies.
• Always consider possibility of multiple foreign bodies

Clinical Features

• Patient history with focus on circumstances/mechanism of symptom onset
  • e.g. use of power tools, projectile weapons, MVCs, metal-on-metal impacts, or high-impact trauma
  • Most common is metal foreign body from hammering

Superficial (embedded in conjunctiva or cornea)

• Eye pain
• Foreign body sensation
• Tearing
• Blurry Vision

Intraocular

• As above, although may additionally be asymptomatic initially and present after complications arise (e.g. corneal ulcer)
• +Sidel's sign

Differential Diagnosis

Orbital trauma

Acute

• Caustic keratoconjunctivitis^^
• Conjunctival hemorrhage
• Conjunctival laceration
• Corneal abrasion, Corneal laceration
• Globe rupture^
• Iridodialysis
• Lens dislocation
• Ocular foreign body
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture
• Posterior vitreous detachment
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
  • Ocular compartment syndrome
• Subconjunctival hemorrhage
• Traumatic hyphema
• Traumatic iritis
• Traumatic mydriasis
• Traumatic optic neuropathy
• Vitreous detachment
• Vitreous hemorrhage
• Ultraviolet keratitis

Subacute/Delayed

• Corneal ulcer^
• Endophthalmitis^

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Evaluation

Based on patient mechanism/history

• Possible high impact metal (e.g. hammering, use power tools, projectile weapons, metal-on-metal impacts, or high-impact trauma)
  • Eye exam
    • Slit lamp exam with fluorescein
    • Intraocular pressure
    • Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies
  • CT orbit
• Non-high impact metal history (vegetation, dirt, dust)
  • Eye exam only
    • Slit lamp exam with fluorescein
    • Intraocular pressure
    • Extensive ocular exam with lid eversion or sweep to check for subtarsal foreign bodies

Contraindicated

• Ocular ultrasound in setting of open globe injury
• Plain films only detect 40% of IOFB (intra-ocular foreign bodies), so generally not obtained

Management

Superficial ocular foreign body with no signs of open globe injury

• Conjunctival foreign body
  • ED removal after topical anesthetic
    • Copious irrigation
    • Cotton-tipped swab soaked in saline
  • Pain control with topical NSAIDs (e.g. diclofenac or ketorolac) or oral opioids
  • Consider Cycloplegics (e.g. cyclopentolate or homatropine) for photophobia
  • Tetanus booster as needed
  • Consider topical antibiotics for corneal involvement
• Corneal foreign body

• • 30- to 25-gauge needle under slit lamp
  • Repeat Seidel test to ensure removal did not perforate cornea
  • Irrigate eye profusely post-removal
• Pain control with topical NSAIDs (e.g. diclofenac or ketorolac) or oral opioids
• Cycloplegics (e.g. cyclopentolate or homatropine) for photophobia

• Consider topical antibiotics for corneal involvement
  • Target gram-positive + pseudomonas (contact wearers)
  • Moxifloxacin – best ophthalmologic penetration
• Schedule follow-up with ophthalmologist

Intraocular foreign bodies or concern for open globe injury

• Emergent ophthalmology consult
• Prophylactic empiric antibiotics
• Placement of rigid eye shield
• Analgesia (oral and topical NSAIDS or opioids) and antiemetics as necessary

Rust rings

• Not a true emergency as many will wash out spontaneously
• May be removed with a 30- to 25-gauge needle as above

Disposition

Outpatient

• Superficial ocular foreign body after removal

Admission

• With emergent surgical intervention for:
  • Intraocular foreign body
  • Evidence of open globe

See Also

• Corneal foreign body
• Corneal abrasion
• Eye Algorithms (Main)
• Corneal Ulcer
• Conjunctival Abrasion
• Foreign bodies