Corneal Foreign Body - Remove or refer?

[Richard_Hom]

This is a 60 year old male who presents from the Emergency Department with a 3 day history of FBS, pain, photophobia. No mucopurulent discharge.

Entrance vision, uncorrected is OD 20/50 and OS 20/25.

Would you take this FB out or refer to another eyecare provider and why?

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[cpw]

Depends on a few factors.. it's near the visual axis, but not on the direct center of the pupil. Although, it is effecting VA. There's no optic section view on your picture so there's no way to tell how deep the metal is penetrating. (if it's too deep I wouldn't touch it, I'd refer)

I'm still too early in my career to have done many foreign body removals and since it is metallic you'd also have to do an algar (sp?) brush to remove and remaining rust ring (which could be done in mutiple visits)

So, there would have to be a different option there for me. Were I later in my career where I had done a few of these I'd probably do it myself. At this point, I'd probably want to do this, but would have someone observe me doing it since at this point I've only ever done one and it was no where near the visual axis (and not metallic).

 

[Richard_Hom]

"...So, there would have to be a different option there for me. Were I later in my career where I had done a few of these I'd probably do it myself. At this point, I'd probably want to do this, but would have someone observe me doing it since at this point I've only ever done one and it was no where near the visual axis (and not metallic).

Dear CPW,

Thanks for your post. If you were to do this yourself:

What instrument(s) would you use?
What after care?

 

[cpw]

For instruments it depends on depth. I've seen some attendings use a spud and some use a small gage needle on the end of a cotton tip applicator. I guess in some ways it depends on the penetration depth. You'd also want to remove any remaining rust ring with an algar brush (have them come back the next day if you could not remove all the rust in one visit)

For after care you'd want a prophylactic antibiotic (probably Vigamox) , maybe an antibiotic steroid combo. Since the eye is painful I'd also cyclopledge the patient to help relieve the pain and photophobia. I would not pressure patch (although I've seen some people that do) the patient should return in one day for a follow up.

 

[JennyW]

Depends on a few factors.. it's near the visual axis, but not on the direct center of the pupil. Although, it is effecting VA. There's no optic section view on your picture so there's no way to tell how deep the metal is penetrating. (if it's too deep I wouldn't touch it, I'd refer)

I'm still too early in my career to have done many foreign body removals and since it is metallic you'd also have to do an algar (sp?) brush to remove and remaining rust ring (which could be done in mutiple visits)

So, there would have to be a different option there for me. Were I later in my career where I had done a few of these I'd probably do it myself. At this point, I'd probably want to do this, but would have someone observe me doing it since at this point I've only ever done one and it was no where near the visual axis (and not metallic).

OF COURSE you should remove that! That's not even close to the visual axis. From that photograph, it looks like it's even outside of the pupillary margin.

And maybe this is just the hormones talking since I had a baby 3 weeks ago, but how can you be entering your 4th year and not know how to spell Alger Brush??

Jenny

 

[cpw]

And maybe this is just the hormones talking since I had a baby 3 weeks ago, but how can you be entering your 4th year and not know how to spell Alger Brush??

Jenny

probably cuz i've never used one... and I also freely admitted I wasn't sure of the spelling.

 

[aphistis]

OF COURSE you should remove that! That's not even close to the visual axis. From that photograph, it looks like it's even outside of the pupillary margin.

And maybe this is just the hormones talking since I had a baby 3 weeks ago, but how can you be entering your 4th year and not know how to spell Alger Brush??

Jenny

Your cheery personality always brightens my day, Jenny.

 

[cpw]

Dr Hom, I'm assuming you took it out? (since you took pictures and all) 😉

 

[PBEA]

small and superficial, I'd use nylon loop or spud. Minimal rust ring might not need alger, thereby preserving off-visual axis. Irrigate and Rx AB (flouroquinolone) with AT. RTC 1 day. I'd stay away from steroid until epithelium is healed, even with AB cover. Cyclo with further sign and symptom. DFE/gonio if penetrating FB suspect.

 

[Richard_Hom]

Dr Hom, I'm assuming you took it out? (since you took pictures and all) 😉

Yes, I did. I used a 25 gauge needle, and with a cotton-tipped applicator dabbed with Erythromycin ointment lifted off the FB. Taped the FB into the physical chart. I recommend this if you have paper charts. Debrided with Alger Brush and covered with Erythromycin oph ung QID. For pain relief, cyclopentolate 1%, 1 gtt, TID. Patient advised to return in 1 day.

Richard

 

[Tony.]

For instruments it depends on depth. I've seen some attendings use a spud and some use a small gage needle on the end of a cotton tip applicator. I guess in some ways it depends on the penetration depth. You'd also want to remove any remaining rust ring with an algar brush (have them come back the next day if you could not remove all the rust in one visit)

For after care you'd want a prophylactic antibiotic (probably Vigamox) , maybe an antibiotic steroid combo. Since the eye is painful I'd also cyclopledge the patient to help relieve the pain and photophobia. I would not pressure patch (although I've seen some people that do) the patient should return in one day for a follow up.

cpw,
what does 'photophobia' mean?

 

[Andrew_Doan]

Photophobia means severe sensitivity to light (painful).

Also, using a needle may be safer than the Alger Brush. I usually just use a TB needle bent at the tip to remove the foreign body.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=2012370

A comparison of rust-ring removal methods in a rabbit model: small-gauge hypodermic needle versus electric drill.

Liston RL, Olson RJ, Mamalis N.

Ann Ophthalmol. 1991 Jan;23(1):24-7.

Department of Ophthalmology, University of Utah School of Medicine, Salt Lake City.

Corneal rust rings are common findings after removal of a metallic foreign body. These rings should be removed to prevent inflammation and scarring. We compared the corneal damage in rabbit eyes caused by rust-ring removal using two different methods: a small-gauge hypodermic needle and a hand-held electric ophthalmic drill. No significant difference was found in the amount of corneal scarring as graded by a masked observer. However, there was a trend toward deeper stromal damage in the drill-treated subjects (207 +/- 73 microns) than in the needle-treated subjects (172 +/- 61 microns). In light of this finding, we suggest caution in removing central rust rings with an electric drill since an avoidable, permanent scar may result.

 

[Richard_Hom]

Photophobia means severe sensitivity to light (painful).

Also, using a needle may be safer than the Alger Brush. I usually just use a TB needle bent at the tip to remove the foreign body.

Thanks so much for you post. I recommond familiarity and competency with needles for fb removal b/c they are ubiquitous and sterile.

"on a jornada"

 

[GeddyLee]

Man...I'm just glad you removed it...and not the ED physician. Those guys scare me with their burr.

 

[maxwellfish]

WOW 200+ views... 9 votes!

 

[Tony.]

Photophobia means severe sensitivity to light (painful).

.

eeesh! I should have known that...

photo = light
phobia = scared of


👍
I think i learned that in my medical terminology class a few years ago