Ophthalmology
Eye Foreign Body and Corneal Abrasions
Background
- Definition
- Eye foreign body (FB)
- Corneal abrasion
- Eye injury that causes significant discomfort, photophobia and erythema
- Aka scratched eye, scratched cornea
- Synopsis
- Both are common eye injuries responsible for ED visits
- Also common workplace eye injuries
- Management consists of
- Removal of foreign body before it induces corneal abrasion
- Management of abrasions with anti-microbials, pain control, physical shielding (e.g., eye patch, goggles, etc.)
Pathophysiology
- Mechanism
- Traumatic corneal abrasion:
- Mechanical trauma to eye
- Leads to abrasion defect in epithelial surface (corneal epithelium)
- Foreign body induced:
- Abrasions remain after removing/spontaneous dislodging corneal foreign body
- Outer epithelial layer of cornea disrupted
- Contact lens-induced:
- Abrasions remain after removing over worn, improperly fitting or dirty contact lens
- Spontaneous:
- As a result of no immediately preceding injury/foreign body trauma
- Low-velocity projectiles:
- May embed in cornea
- May be entrapped between upper eyelid & cornea
- High-velocity projectiles:
- May embed deeper into cornea and injure deeper structures
- Annular "rust rings":
- Surround a retained ferrous foreign body
- May develop within a few hrs
- Chemical/heat abrasions:
- Causes burns and scarring
- Exposure to UV radiation (see UV keratitis)
- Etiology/Risk Factors
- Traumatic corneal abrasion
- Fingernails, piece of paper/cardboard
- Cosmetic makeup applicators, hand tools
- Foreign body-related
- Tree branches, workplace debris
- Sports equipment
- Contact lens related
- Chemical/heat abrasions
- Sand, other small particles
- Spontaneous
- Previous abrasions and defects
- Exposure to UV radiation
- UV light and welding arcs or sun lamps
- Epidemiology
- Incidence/Prevalence
- ED visits (8% eye injury)
- 87% corneal abrasions
- 3% of ED visits
- 2% of visits in primary care clinics (eye complaints)
- FBs responsible for 8% of these visits
- Workplace eye injuries
- 15 cases/1000 employees (US autoworkers)
- 87% are corneal abrasions
- Prevalent among contact lens wearers
- Common in all age groups
- Mortality/Morbidity
- Pain, headaches
- Blurred vision (can be permanent)
- Blindness in affected eye
- Foreign can continue moving outward and become an open globe injury
Diagnostics
- History/Symptoms
- Excruciating sudden eye pain
- Inability/difficulty to open the eye
- Uncomfortable to do routine things
- Washing eye causes exacerbation of discomfort
- +/- tearing, photophobia
- Decreased visual acuity
- Pain dramatically relieved by topical anesthetic
- Surrounding eye muscle spasms
- Awaken in the middle of night
- Rule out
- Penetrating trauma
- Infectious infiltration
- +/- contact lenses
- Flying/material falling into eye
- Place of employment
- Hobbies (working w/ wood or metal, etc)
- History of any prior traumatic abrasion
- Awakening middle of night with eye pain
- Physical Exam/Signs
- See also eye exam in trauma
- Begin exam w/ a penlight
- Abnormally shaped pupil could be a sign of globe rupture
- Topical anesthetic to facilitate exam
- Avoid pressure on the globe
- Note erythematous conjunctiva
- Light sensitivity
- Excessive lacrimation
- Decreased visual acuity
- If blood (hyphema), pus (hypopyon) in anterior chamber
- Ophthalmologist examination that day
- Complete Eye Exam
- Visual acuities examination
- Right (OD), Left (OS), Both (OU):
- Absolutely ESSENTIAL to check & examine
- May be normal if abrasion is not near
- +/- corneal edema
- Visual fields examination
- Check extraocular motion
- Evert and examine/clean under upper and lower lids
- Fundoscopic examination
- Examine cornea and anterior chamber with slit lamp (if avai
- lable)
- Note any anterior chamber cell or flare
- Any abrasions, hypopyon, hyphema, blood, or foreign bodies
- Note red reflex
- Fluorescein exam
- To confirm diagnosis after fundus exam
- Fluorescein stains basement membrane revealing corneal lesion
- Corneal defects - yellow-green fluorescence under woods/slit lamp
- Be sure NO contact lenses
- Findings
- Multiple vertical scratches (ice rink sign)
- Suggest foreign body embedded in upper lid
- If not already performed, evert, and examine under surface of lid
- Streaming/flowing appearance under a defect (Seidels sign, waterfall sign)
- Suggests corneal perforation & possible retained foreign body
- Diffuse uptake (corneal stippling)
- Suggests UV keratitis from welding/sunlight
- Imaging
- Consider ocular radiographs or CT of orbit if suspect intraocular retained foreign body
- Clearly document abrasion location by diagram on chart
- Differential Diagnosis
- Conjunctivitis
- Dry eye syndrome
- Acute angle-closure glaucoma
- Uveitis
- Infective keratitis
- Bacterial
- Fungal
- Herpetic
- Corneal ulcer
- Recurrent erosion syndrome
Treatment
- Initial/Prep/Overview
- Offer dark room to wait in & discourage eye rubbing
- Eye patching (avoid)
- Topical antibiotics
- Topical cycloplegics
- Tetanus prophylaxis
- Indication: penetrating eye injuries
- NOT for corneal abrasion or foreign body
- Symptomatic treatments
- Anesthetic drops (to facilitate exam not treatment)
- Opioids
- OTC (e.g., Refresh PM, Lacri-lube)
- If corneal abrasions with no foreign body
- If foreign body, removal plus post-op Rx (consult ophthalmology or specialist)
- Indications: Pain, foreign body sensation, tearing, photophobia, blepharospasm, and blurred vision
- Contraindications: MRI is strictly contraindicated if suspect metal foreign body
- Medical/Pharmaceutical
- Corneal Abrasions
- Topical antibiotics (See also: Eye anti-infectives )
- Ointment preferred vs drops
- Lubricating
- Drops may sting
- Erythromycin: 0.5 inch ribbon QID for 3-5 days
- Sulfacetamide 10%: 0.5 inch ribbon TID to conjunctival sac, or
- Drops: 1-3 gtt q3h for 3-5 day
- Polymyxin B/ trimethoprim: 0.5 inch ribbon to conjunctival sac QID, or
- Drops: 1-2 gtt QID for 3-5 days
- Ciprofloxacin/ofloxacin: 1 gtt affected eye QID for 1 wk
- Avoid aminoglycosides and steroids (except contact lens abrasion)
- Gentamicin: 1-2 gtt q4h
- Severe infection: 2 gtt q30min for 24 hrs
- Topical cycloplegics (r/o glaucoma)
- Reduces response to light thus pain
- Can relieve photophobia (generally in 2 days)
- Cyclopentolate 0.5%, 1% (short-acting - 36 hrs): 1 gtt TID for 2 days
- Homatropine 2.5%: usually1 drop prescribed
- Severe iritis: Atropine
- Side effects such as difficulty w/ reading
- Topical NSAIDs
- Avoid eye patch, especially in contact lenses abrasions
- Pain control
- NEVER discharge with topical anesthetics
- Not recommended to use topical anesthetics > 24 hrs
- Can prolong resolution time
- May retard healing, potentially mask symptoms of more serious injury
- Mild to moderate pain can be controlled w/ NSAIDs PO
- Contact lens abrasions
- Risk of infectious keratitis
- Adhesion of pathogen to ocular surface/lens
- Pathogen colonization in solutions/lens cases
- Extended wear (during sleep)
- Infectious pseudomonas keratitis
- Ulcerative necrotizing corneal melting/perforation in 24 hrs
- Permanent corneal scarring
- Examine for corneal infiltrate (penlight)
- Findings: white spot, opacity, ulcer
- Never apply eye patch
- Pseudomonal coverage (immediate ophthalmology follow-up)
- Surgical/Procedural (Foreign Body Removal)
- Equipment
- Topical sodium fluorescein
- Topical anesthetic drops
- Slit lamp with cobalt blue filter
- Or Burton lamp with similar filter
- Sterile saline
- Sterile cotton-tipped applicators
- Jeweler's forceps
- 25-g needle attached to a tuberculin syringe, a bent needle tip is optional
- Foreign body spud (consider a magnetic spud for metallic foreign bodies)
- Rotating burr tool (Alger brush)
- Eyelid speculum may be necessary (e.g., strong blink reflex)
- Anesthesia
- Place 1-2 drops of topical anesthetic into lower fornix ≥ 30 seconds before potential contact with cornea
- Conjunctival foreign body (trapped under lid)
- Irrigate (recommended use 18-g syringe technique)
- Use moistened cotton swab under eyelid
- Using swab on cornea may cause a larger abrasion
- Superficially embedded corneal foreign body
- Use cotton swab, spud, or specially prepared 20-22-gauge needle
- Prepare needle by bending to approximately 45 degrees, with bevel facing inner radius of bend
- Use needle with bevel pointing toward you (facing outward from patient eye)
- Edge (NOT point) of bevel is used to gently lift foreign body from cornea
- Syringe may be attached to needle for larger handle
- Carefully dislodge & remove foreign body
- Ophthalmological referral (for all patients)
- Deep injury involving stroma and in visual axis
- Requires ophthalmologic follow-up
- Deeply embedded material
- Refer to ophthalmologist
- If body is small, inert, and outside of visual axis
- Patient may choose to leave in place to minimize scarring/expense
- Rust rings
- May opt to not remove small rings outside of visual axis
- This may slow healing however
- Fresh rings are sometimes more difficult to remove
- Consider later referral to ophthalmologist
- ED removal - buff off the superficial corneal layer with an eye burr (i.e., Alger brush) (View image)
- Refer to ophthalmologist, especially for injuries in visual axis
- Retained intraocular foreign body/punctured cornea (suspected/known)
- Emergent ophthalmology consult
- Apply metal shield to protect eye
- Do not apply direct pressure to globe
- Post-Op
- Initiate a broad-spectrum topical antibiotic no less than 4 times daily for one week
- Larger, deeper, or central defects may require more frequent applications and longer durations
- If habitual contact lens wearer, ensure antibiotic therapy is effective against pseudomonas
- Pain control
- Ophthalmic NSAIDs
- If breakthrough pain, add NSAIDs or Acetaminophen PO
- Schedule III controlled drugs may be necessary (rarely)
- Amniotic membrane therapy
- May be beneficial in reducing residual scarring while encouraging epithelial healing
- Bandage soft contact lens
- Relieves pain, correct vision, and reduce surface disruption associated with blinking
- Pressure patching
- If large concomitant corneal abrasion
- Complications
- Corneal ulcers
- Bacterial keratitis
- Recurrent erosion syndrome
- Traumatic iritis
Disposition
- Admission criteria
- Admit with consult recommendations
- Consults
- Discharge/Follow-up instructions
- Most corneal abrasions heal regardless of therapy
- In 24-72 hrs or overnight
- Follow-up with PCP or ophthalmologist
- Abrasions < 3 mm - usually not necessary
- Contact lens abrasions - daily follow-up until healed
- Abrasions > 3 mm - require close follow-up
- General disposition guidelines if not requiring emergent ophthalmological consult
- D/C with instructions
- Do not (especially if patched)
- Drive, ride bike, skate
- Read
- Excessive exercise or exertion
- D/C with superficial abrasion or rust ring not in visual axis
- Return if increasing eye pain/vision changes
- Do not discharge patient with topical anesthetic drops or topical steroids
- Instruct patient not to use contact lenses until eye is healed (at least 24 hrs)
- Caution early after fluorescein exam
- May permanently stain lens
- Eye rubbing decreases healing
- If left untreated, may lead to corneal ulcers
Related Topics
References
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Contributor(s)
- Lo, Bruce, MD, FAAEM
- Singh, Ajaydeep, MD
Updated/Reviewed: November 2023