ocular foreign body
TRANSCRIPT
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Ocular Foreign Bodies
Runal Shah2nd year Resident,
Masters in Emergency MedicineKDAH
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Objectives
i. Basicsii. Clinical Presentationiii. Practical scenarioiv. Treatment modalitiesv. Specialist care
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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
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Basics
Foreign body classificationi. 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
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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
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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
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Practical Scenario
We don’t have these
Slit Lamp Alger Brush
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Examination
Upper lid eversion and conjunctival fornices examination
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Treatment Modalities
Moistened Cotton tip applicator 25G needle on syringe
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Topical Anesthetic Eye drops
• Proparacaine 0.5% to anesthetize cornea before attempted FB removal.
•Anesthetizing both eyes is helpful, as it eliminates reflex blinking.
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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!
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Topical antibiotics
Moxifloxacin Ciprofloxacin
Other Antibiotics – • Polymixin-B+Trimethoprim (Polytrim)
• Ofloxacin• Gatifloxacin• Bacitracin• Tobramycin (Tobrex)
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Specialist Consultationo Hyphema (blood in anterior chamber)o Diffuse corneal damageo Scleral / corneal lacerationo Lid edemao Diffuse subconjunctival hemorrhageo Posttraumatic pupillary dilatation/ abnormal pupil
shapeo Abnormally shallow/ deep anterior chamber compared
to fellow eyeo Persistent corneal defect / corneal opacityo Possibility of full penetration / sclera
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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.
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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.
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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