Conjunctival and Corneal Foreign Object Removal

E. J. Mayeaux, Jr., MD, DABFP, FAAFP and Man T. Ton, MD
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Subject: Conjunctival and Corneal Foreign Object Removal

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Introduction

Conjunctival and corneal foreign objects are commonly seen problems in the primary care office and in the emergency department. Removal of the foreign object is usually easy accomplished and can be performed in the outpatient setting. When a patient presents, document a thorough history including job type, the condition of the eye before injury, probable type of foreign body (especially if it may be iron based), mechanism of injury, and whether first aid was rendered. Always test and document the patient’s vision before and after treatment. Use a Snellen chart or an equivalent visual acuity chart if possible. 
Because of the risk of complications, obtaining informed consent is a necessity prior to treatment. Possible complications of foreign body removal include infection, incomplete removal of a foreign body, perforation of the cornea, scarring, and permanent visual impairment. Special care must be taken with iron-based foreign objects, because rust is toxic to the cornea and may prevent it from healing. 
The corneal and conjunctival epithelia are some of the fastest-healing areas of the body. If considerable progress toward healing has not been made within 24 hours of foreign body extraction, re-examine for additional foreign bodies or signs of infection. Pain may be an important indicator of developing corneal ulceration or the presence of an additional foreign body. Therefore, local anesthetic drops and topical steroids should not be prescribed for outpatient use. The other reasons to avoid local anesthetic drops are because they may retard corneal healing and might lead to corneal perforation. They are often used during mechanical removal of foreign objects in the clinical setting only. 
If the patient has significant pain, consider using a cycloplegic agent to decrease spasm of the iris. Apply antibiotic drops or ointment for prophylaxis. An ointment may be better than drops because of its lubricant effect and ability to help reduce disruption of the newly generated epithelium. Oral pain medication should be prescribed as indicated. Instruct the patient not to rub the eye, because it may disrupt the new epithelial layers of the cornea. 
Traditionally, eye patches were applied, on the theory that they decreased photophobia, tearing, foreign body sensation, pain, and healing time. However, studies indicate that patching does not improve pain scores, healing times, or treatment outcomes. It may also decrease patient compliance with treatment plans. 
Clinicians must use extreme caution when attempting to remove foreign objects by mechanical means such as cotton-tipped applicators or needles. Object removal is most successful in cases of recent, superficial foreign bodies. Any downward pressure on the object may result in more damage to the epithelium or deeper layers. If clinicians are unsure of their ability to remove an object without exerting downward pressure on it, the patient should be referred to an ophthalmologist for removal. 
Re-epithelialization is complete in 3 to 4 days for more than 90% of patients, but it can take weeks. Re-examine every 24 hours until the eye is healed. Perform and document a visual acuity test on the last visit. Continue antibiotic drops or ointment for an additional 3 days after the eye is free of symptoms. The patient may be unusually receptive at this time to education about eye safety measures such as protective eyewear. If the pain increases at any time during the follow-up or signs of conjunctival or orbital infection are seen, immediately refer the patient to an ophthalmologist. 
It is important to know when to refer patients to an ophthalmologist to decrease the risk of impaired vision or blindness. Indications for immediate referral include an intraocular presence of an object, a large corneal epithelial defect, a corneal infiltrate or white spot, corneal opacity, or a purulent discharge. The patient should also be referred to an ophthalmologist immediately for any chemical injury, or if pain or functional impairment persists after irrigation. Possible acid or alkali contamination of the eye is a true ophthalmologic emergency. 

Equipment

  • A Snellen chart or equivalent visual acuity chart can be obtained from Premier Medical, P. O. Box 4132, Kent, WA 98032. Phone: 1-800-955-2774. Web site: http://premieremedical.safeshopper.com

  • Medications: topical ophthalmic anesthetic (e.g., tetracaine [Pontocaine] or proparacaine [Opthetic]), cycloplegic drops, topical antibiotics ointment (e.g., erythromycin [Ilotycin], bacitracin, or sulfacetamide).

  • Magnification devices, loupes, and Wood’s lights may be ordered from medical supply companies. Fluorescein strips may be ordered from pharmacies.

  • Other materials: cotton-tipped swabs, hypodermic needle (26 gauge), sterile water, bag of normal saline with IV drip tubing, ophthalmoscope.

Indications

  • Small, conjunctival, or corneal foreign bodies embedded <24 hours

Contraindications

  • Foreign bodies embedded in the cornea for >24 hours (i.e., risk of infection)

  • Iron-based foreign bodies, which may cause a rust ring (relative contraindication)

  • Uncooperative patient

  • Deeply or centrally embedded foreign bodies (i.e., ophthalmologic referral)

  • Possible acid or alkali contamination of the eye (i.e., ophthalmologic emergency)

  • Ruptured globe (i.e., ophthalmologic emergency)

  • Hyphema, lens opacification, abnormal anterior chamber examination, or irregularity of the pupil (i.e., possible ruptured globe, which is an ophthalmologic emergency)

  • Signs or symptoms of infection (i.e., ophthalmologic referral)

The Procedure

Step 1

Check and record the patient’s visual acuity using a Snellen chart. 

Step 2

Position the patient in the supine position. For corneal foreign bodies, position the patient’s head so that the foreign body and the eye are in the most elevated position. For conjunctival foreign bodies, position the head to give the examiner maximal access to the affected area. 

Step 3

Hold the patient’s eyelids apart with your thumb and index finger of the nondominant hand. Ask the patient to fix and maintain his or her gaze on a distant object and to hold the head as motionless as possible throughout the procedure. 
  • PEARL: A wire eye speculum may be used but usually is not available in primary care offices.

Step 4

If a foreign body under the lid is suspected, evert the eyelid by placing the cotton-tipped swab on top of the lid and roll the lid over the swab. 
  • PITFALL: Vertical scratches on the cornea may indicate a foreign body embedded in the upper lid, necessitating eyelid eversion and examination with a cotton-tipped applicator.

Step 5

If the object is not readily visible, put two drops of topical anesthetic into the retracted lower eyelid while the patient gazes in an upward direction. Wet a fluorescein strip with the same solution. Apply the fluorescein strip to the underside of the lower eyelid. 

Step 6

Inspect the cornea under a Wood’s light for dye pooling near objects or abrasions that may help identify the location of a foreign body or demonstrate an abrasion. 
  • PITFALL: Putting drops directly on a scratched cornea can be very painful.

Step 7

Attempt to wash out the object using sterile normal saline or an ophthalmic irrigant. This may be done by pouring a small, continuous volume of fluid into the affected eye. An alternative method is to place an intravenous bag of normal saline with tubing on a pole, cut off the end of the tubing, and use the gentle stream coming from the end of the tubing to irrigate the eye. 

Step 8

If this is unsuccessful, attempt to dislodge the object using a cotton-tipped applicator or corner of a soft cotton gauze. Moisten the cotton with local anesthetic, and gently lift the object by lightly touching it. 
  • PITFALL: Never use force or rub the cornea because this can produce pain, damage the epithelium, and cause deeper corneal injuries.

Step 9

If the object is still lodged, a sterile needle may be used to remove the object. Place a 26-gauge needle on a tuberculin syringe and hold it in with a pencil grip. Stabilize your operating hand on the patient’s brow or zygomatic arch. Approach the object with the needle bevel upward from a tangential direction. 

Step 10

Use the needle tip to gently lift the object. Turn the patient’s head laterally, and copiously irrigate the eye. Retest and record the patient’s visual acuity. 
  • PITFALL: If the object cannot be readily removed, refer the patient for removal under slit lamp by an ophthalmologist.

  • PITFALL: If any residual corneal rust is found, immediately refer the patient to an ophthalmologist because rust is toxic to the corneal epithelium.

Step 10
Step 10

Complications

  • Infection

  • Perforation of the cornea

  • Scarring

  • Visual impairment

  • Corneal ulceration

Pediatric Considerations

The history is less specific, because the child might not be able to describe the symptoms or the mechanism of the injury. Any time a child cannot or refuses to open an eye, penetrating trauma must be ruled out. After that, an attempt to measure visual acuity with an age-appropriate technique is recommended. Topical ophthalmic anesthetic can be used to facilitate the examination, which is similar to that in an adult. Warn the child and the parents that the anesthetic will cause a burning sensation at first. 

Postprocedure Instructions

For small abrasions (<3 mm), no follow-up is necessary if the patient’s vision is good. Contact-lens-related abrasions required daily follow-up until the abrasion is healed to avoid ulceration. Large abrasions (>3 mm) with a symptom of decreasing vision require close follow-up. 

Coding Information and Supply Sources

All of the necessary supplies can be obtained from hospital supply houses or pharmacies. 

Bibliography

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