FB Removal PDF

Of all of the ER visits related to ocular trauma, 24% are ocular foreign bodies (more common in men in their 30s) Vast majority are minor ocular trauma ○ Small particles embedded in the corneal epithelium or stroma when projected with force Any type of F...

Of all of the ER visits related to ocular trauma, 24% are ocular foreign bodies (more common in men in their 30s) Vast majority are minor ocular trauma ○ Small particles embedded in the corneal epithelium or stroma when projected with force Any type of FB will produce an inflammatory reaction in the eye Vasodilation of the surrounding tissue will be seen leading to edema ○ Edema of conjunctiva, lids &/or cornea may be present WBCs will be released in reaction to the FB ○ This creates an A/C reaction and/or corneal infiltrates If the FB are not removed, may lead to an infection or create tissue necrosis producing neovascularization FB Types Organic ○ Animal or plant origin ○ Higher rate of fungal infection Inorganic ○ Non-metallic Objects not composed of a living organism Sand, plastic, stone, glass Typically causes less inflammatory reaction ○ Metallic An object composed of metal May lead to the creation of rust rings Most common symptoms of FB Tearing Pain FBS Light sensitivity Decreased vision Hyperemia Photophobia Location of FB Superficial FB (we treat these in office) ○ If removed promptly, it typically does create permanent sequelae ○ The longer the FB remains in eye, even if superficial, greater risk of complications such as infections, ulcers, and/or scarring Intraocular FB (refer) ○ Penetrates the anterior or posterior chamber ○ Can cause: Infection, endophthalmitis  Iris, lens, or retinal damage Impair the BCVA Indications of a penetrating Intraocular FB (IOFB) (+) Seidel sign ○ ○ Perform a Seidal test on all FB patients Shallow anterior chamber ○ High indicator FB closer to cornea or lens Hyphema Iris/pupil irregularities (non-reactive pupil or big pupil) Break in Descemet’s membrane Traumatic cataract Important to R/O full thickness lacerations ○ Full-thickness small foreign bodies may be self-healing due to the heat of the penetrating injury Iris and pupillary abnormalities may be seen ○ Such as a peaked iris ○ Iris prolapse; (-) Seidel test Conjunctival Healing (not as painful as cornea) Defects in the conjunctival epithelium will heal through the migration of cells and mitotic proliferation Proliferation of the basal layer reestablishes the normal thickness of the epithelium Conjunctival abrasions are as large as 1 cm and can be re-epithelized within 48-72 hours Conjunctiva is a highly vascularized tissue Conj. is an inflammatory cascade initiated with damage to the conjunctival epithelium Inflammatory mediators produce vasodilators leading to edema and erythema of the eyelids and conjunctiva Immunocompetent cells act as a source of immunoglobulins Conjunctival cells have microvilli and enzymatic activity that engulf and neutralize viruses and other foreign substances Corneal Healing Corneal healing mechanism are in place to aid in proper repair and preservation of corneal structure after an injury Corneal layers ○ Epithelium Approximately 50 um thick Constant turnover of the entire epithelium process is accelerated during healing ○ Bowman’s layer Maintains rigidity, very resistant to penetration, but if penetrated will scar ○ Stroma Thick layer with collagen fibrils, proteoglycan aggregates and keratocytes (help maintain integrity) If there is damage here, edema and haziness presents ○ Descemet’s membrane Formed by the endothelium and can regenerate ○ Endothelium Maintains deturgescence by pumping excess fluid of the stroma Cannot regenerate Differential diagnosis of abrasion Corneal and conjunctival foreign bodies may resemble abrasion Similar history of:  ○ Ocular trauma ○ Symptoms and signs But no FB will present Examination History is key in FB presentations Important to have a well-documented record ○ Symptoms: FBS? Pain? Tearing? Redness? All the time/sometimes? Open/closed eye? Time and place: the longer since the incident, the higher the risk of inflammation, infection and rust ring FLORIDA (Frequency, Location, Onset, Relieving factors, Intensity, Duration, Associated factors) ○ Actions taken in an attempt to remove/relief: Flushed with water or saline? Attempted to remove? Important to ask ○ What? What is the entering substance? Glass, metal, wood? ○ When? When did this occur/happen? The longer the time after the event, the higher the risk of infection, inflammation and rust ring development ○ Where? Where did this happen? At home, work, outside, inside, protective eyewear? ○ How? How did this occur? Fast moving object, wind blew in face? ALWAYS VA (Aided, Unaided, PH) After VA, can instill anesthesia Pupils EOMS (if EOMs not full, assume fracture) SLE (optic section gives us depth and size since we want to see where FB is) ○ Conjunctiva and cornea ○ FB location, depth, and size  ○ Rust ring presence ○ Anterior chamber signs ○ Epithelial defect of conjunctiva or cornea ○ Corneal edema SLE evaluation ○ Eyelid eversion Upper eyelid/lower eyelid ○ A/C Cells and flare evaluation Ciliary injections: sign of traumatic iritis Abnormally deep A/C ○ Fl staining Tracks, pooling (abrasion) Seidel test (perforation) Seidel Test Equipment: ○ Fl strip ○ Topical anesthetic ○ Slit lamp w/ cobalt blue False negatives may be seen in small defects that have self healed, a large laceration that has plugged or a retrobulbar rupture ○ If there is a strong suspicion for a globe rupture, with a negative Seidel test, next step is an orbital CT scan Positive Seidel will present a “waterfall” effect where the center of the waterfall will not have fluorescein present ○ Positive test indicated a full thickness corneal or scleral injury https://youtu.be/GlFcAv0DR4c https://youtu.be/TNZzogrdJEE?si=TJ1gnKOuVYDRx8fX https://youtu.be/GlFcAv0DR4c Indications ○ Pupillary defect ○ Laceration through eyelid ○ Shallow A/C ○ Blood in A/C: hyphema ○ Bullous subconjunctival heme  ○ Post-surgical with concern for leak ○ Evaluation of corneal laceration to evaluate if sealed ○ Corneal perforation secondary to degeneration Contraindications ○ Obvious globe rupture ○ Full-thickness eye laceration ○ Obvious corneal perforation ○ Hypersensitivity to fluorescein dye Suspected IOFB DFE to elevate retina/periphery Plain X-rays ○ If negative, perform other tests ○ NEVER MRI unless 110% that FB is not metal B-scans Ultrasound biomicroscopy (UBM) Anterior segment OCT Orbital CT scan If metal IOFB, a tetanus shot is necessary FB removal instruments Golf club spud (Straight and Golf Spuds) ○ Rounded or pointed tips, angled or straight ○ Most have sharpened edges ○ Safer than needles ○ FB forceps: useful for anything stuck in the eye but not lodged ○ Used for epilating eyelashes, not recommended for FB Nylon loop with magnet on opposite side Needles ○ Used for smaller and delicate FB; can penetrate cornea so must be proficient ○ Useful for removing symptomatic concretions and conjunctival cyst ○ Sharp edges cuts tissue if needed to dislodge the FB ○ Caution should be taken since this can penetrate deeper corneal layers ○ Needle of choice is a 25G  Bevel up (Bevel is the curve, should be facing up) Tangential approach (never go directly forward, coming from the side) https://youtu.be/rm_nAafFszs Sterile cotton tip applicator: easy and less damage to surroundings Lid retractor: double lid eversion to remove any high FB Alger brush ○ Rust ring removal ○ Hand-held drilling burr ○ Stops if too much pressure is applied ○ Used as a brush, rather than a burr Use sweeping motion to remove rust ring ○ Can also be used to scrape epithelium in order to create a smooth surface in cases of large epithelial loosening ○ https://youtu.be/nb4nNTys4Zw ○ Disinfection tray with cover Post removal instruments CDC recommendations: any reusable equipment should be thoroughly disinfected Bleach 1:10 dilution: 15 minute soak Glutaraldehyde 2% (Sporicidin/Opticide): 20-minute soak Autoclave Conjunctival FB removal Superficial Conjunctival FB ○ Determine the # of foreign bodies (single or multiple) ○ Identify the location of the FB superior/inferior, palpebral/bulbar ○ Assess the degree of embeddedness of the FB ○ Topical anesthetic solution is avoided unless the patient is very uncomfortable, if there is significant blepharospasm or the FB is substantially embedded Once removed the patient will feel relief ○ Most common location for conj. FB is on the superior conjunctiva ○ Bulbar conjunctival FB are easily located ○ If pt symptomatology suggests FB, but it is difficult to visualize lid eversion has to be performed, if needed double eversion ○ Classical sign: corneal tracks Double lid eversion ○ Used to inspect the superior conjunctival fornix ○ Anesthetize, perform a lid everson and then using a retractor between the lid surface engage the tarsus ○ Gently pull outward and upward to expose the fornix Once the FB is located in the conjunctiva ○ Irrigation or sterile cotton tip applicator might dislodge the FB by sweeping ○ If embedded, it may require the use of a sterile spud or a disposable needle If it cannot be dislodged: ○ Using a 10-16X magnification and diffuse illuminate in medium-high intensity ○ Align the instrument close to the patient’s eye, while looking from the outside Once aligned, look through oculars ○ Stabilize your hand Headrest, elbow on table/block  ○ Approach the FB tangentially, never perpendicular ○ Slowly loosen the edges of the FB, once loosened use a flicking motion to lift off ○ If necessary, use other FB removal instruments to completely remove the FB If after removal the FB cannot be located ○ Irrigate the superior and inferior cul de sac and swap with a moistened cotton tip applicator the conjunctiva After FB removal Perform an SLE after irrigation to assess anterior segment structures Observe ○ Hyperemia ○ Ischemia ○ Chemosis ○ Staining w/ fl ○ Epithelial compromise Punctate keratits ○ Corneal edema Post-removal of superficial conjunctival FB After the removal of the FB, a conjunctival abrasion will be left Prescribe ophthalmic antibiotic solution or ointment for prophylaxis ○ Polytrim ophth soln 1 gtt q 6 hr in affected eye ○ Polysporin ung ¼ in ribbon in inf cul de sac q 6-12 hr Cycloplegia or BSCL are rarely needed Conjunctiva heals within 12-24 hrs ○ F/U as needed Instruct to RTC if FBS persists or new symptoms F/U in 5-7 days Contraindications and complications Secondary infections are possible, more common in embedded FB Superficial Punctate Keratitis ○ Could result after irrigation due to mechanical disruption of the cornea Reassure the patient about possible subconjunctival hemes secondary to FB removal FB in bulbar conjunctiva may cause a perforating injury, especially if caused by a high-speed projectile ○ I.e., hammering, grinding material Performing injury masked by SCH ○ Seidel test ○ Radiological studies of the eye and orbit ○ Refer if signs of perforation are present Contraindications for removal Posterior stroma or deeper/suspected globe penetration  ○ Refer for removal Hyphema Laceration of cornea or sclera Dilated pupil or abnormally shaped pupil Very deep or shallow A/C ○ Compare to the other eye Multiple FB Extremely uncooperative patient ○ Young child, intoxicated or patient w/ mental instability Significant lid edema or diffuse SCH ○ R/O IOFB If superficial irrigation should be tried first Have patient fixate a target Recline the patient’s head Raise the upper lid and with the opposite hand irrigate with sterile saline solution If the FB dislodges into the cul de sac, use a sterile cotton tip applicator moistened with saline to remove it If irrigation does not dislodge the FB: FB golf spud or sterile disposable needle FB nylon loop: Flexible ○ Good for patients with poor fixation Sterile cotton tip applicators are not recommended since it may disrupt the surrounding epithelium and may also fragment the FB ○ A better choice for conjunctival FB Golf spud or needle: Place the patient in the SL aligned and with a fixation target Using 10-16X magnification, diffuse illumination or wide parallelepiped and medium intensity Stabilize your hand and hold the instrument in the same manner a pencil is help, between thumb and index finger Position the instrument in front of the eye at a tangential angle to the cornea ○ Not parallel or perpendicular Secure the eyelid with the other hand if necessary Using small strokes, loosen the edges of the FB  ○ Needle: bevel facing you Keeping the tangential approach, insert the spud or needle tip beneath the FB and release Nylon loop: Align the loop by sight outside the SL, position it in front of the FB at a tangential angle to the cornea Once aligned, using the SL, hold the loop tangential and tease the edge of the FB loosening it from the epithelium Insert the loop beneath the FB and use a subtle flicking motion to release it from the corneal surface Magnet: If the FB is metallic in nature, a magnet can be used Bring close to the FB in an attempt to remove Reduces further trauma to cornea, allowing for quicker healing Made of stainless steel During and after corneal FB removal Wrinkling of the cornea: ○ Can appear as mild pressure is applied w/ an instrument Epithelial defect: ○ After FB removal, an epithelial defect will be left  ○ Treat w/ antibiotic and lubricant drops ○ If needed a BSCL or a pressure patch can be applied After a metallic FB: ○ Rust ring may be present and needs to be removed Alger brush Edema may be present while the cornea heals Embedded FB: ○ May cause anterior uveitis for some time, which needs to be managed Rust ring removal Align the Alger Brush tangential to the rust ring in the cornea ○ Look outside the SL, once aligned look through oculars Secure the upper eyelid with your opposite hand or a speculum if necessary Hold the Alger Brush as a pencil, tangential to the cornea Touch the rust ring and apply gentle pressure in a sweeping movement If using a spud or needle scrape away the epithelium that has rust Irrigate with saline solution after removing rust ring Mild pressure will cause corneal wrinkling When using the Alger Brush a noticeable amount of epithelium debris will be generated and a small crater will remain ○ Treat as corneal abrasion Ring of edema will remain, surrounding the defect until healing If a FB and rust ring were present for a substantial period of time, anterior uveitis may develop If rust ring varies in consistency, use a combination of techniques Spud for solid and Alger Brush for softer component If too difficult or deep to remove, it is best to leave until it leaches out spontaneously F/U if not spontaneously resolved use rust ring removal techniques Post corneal FB removal Broad-spectrum antibiotics for 7 days BSCLs reduces discomfort, protects the epithelium, promotes healing and decreases risk of corneal erosion In a non-CL wearer it may cause discomfort or may become dislodge May contribute to a more infective climate Monitor closely Remove CL in 24 hrs and evaluate for edema and striae Pressure patch can help with pain, but will leave the patient with no binocular vision Usually not needed, but some benefit from them F/U in 24 hours Non-central superficial corneal FB usually just need topical antibiotic If inflammation or the amount of burring was extensive: ○ Homatropine BID/3 days, Topical antibiotic Steroids are contraindicated until re-epithelization occurs  ○ Even in uveitis/iritis presentation ○ After re-epithelization if needed can be started ○ Keep in mind steroids decrease healing and can lead to a superinfection Amniotic membrane for central, deep corneal FB, where there are greater scaring risks For large abrasions Muro128 (NaCl 0.05%) is recommended Pain management Depends on tissue damage extension, depth of FB, inflammation and infections ○ Mild to moderate presentation consider topical or oral NSAIDs or acetaminophen 1st 24-48 hours with moderate to severe pain: ○ Opioid analgesic afents Hydrocodone/Acetaminophen (Vicodin) Oxycodone/Acetaminophen (Percocet) Other corneal/conjunctival emergency Cyanoacrylate “Krazy Glue” ○ When dried, creates hard particles which may cause injury In emergency situations, it has been used as treatment instead of stitches ○ Glue will bond with dry surfaces The lashes or collects in the lower conjunctival fornix ○ Most common injuries: glued lids/lashes, conjunctivitis or corneal abrasions ○ Treatment if the eye CAN be opened: Irrigate if there is discomfort or conjunctival injection Use anesthetic drops if needed Look for glue on the ocular surface and lids (evert) Fluorescein will reveal glue which can then be removed with a cotton tip applicator Remaining pieces may need to be removed with the SL and forceps Evaluate for corneal abrasions Ab ung such as Erythromycin ung QID ○ Treatment if the eye CANNOT be opened: Moisten glue w/ warm water Remove as much glue as possible without causing damage Try to separate the lids gently Lashes may need to be cut if needed Evaluate for corneal abrasions  Ab ung such as Erythromycin ung QID ○ Do not patch ○ F/U in 2-3 days if not corneal abrasion ○ If corneal abrasion F/U in 24 hrs Chemical injury Injury can be acid or alkaline They represent 11.5-22.1% of ocular traumas Alkali agents are lipophilic (alkali will eat through tissue) ○ Penetrate tissue more rapidly than acids Acid agents are less harmful ○ Cause damage by denaturing and precipitating protein, which create a barrier to prevent further damage Before any examination, the pH of the eye has to be evaluated Place a pH strip in the lower palpebral conjunctiva If not in physiologic range (7.0-7.4) irrigation is warranted to neutralize the pH Copiously irrigate the eye with sterile saline solution and retest the pH 5 minutes after to avoid altering the results with residue Once the pH remains neutral for 5 minutes after irrigation you may stop irrigating After neutralizing pH evaluate SLE S/I palpebral conjunctiva, bulbar conjunctiva and cornea for any damage and treat accordingly Clinical pearls Visual acuities provide important clues ○ Less than 15% of FB cases have 20/40 or better in cases of full-thickness lacerations Shields if needed to protect the eye while sleeping Anterior chamber reaction indicates a traumatic iritis ○ If a hyphema is present consider a full-thickness laceration with a retained FB until proven otherwise Retained FB have to check if they have toxic consequences Corneal laceration must rule out IOFB with a DFE Anterior Segment OCT will provide information on full or partial thickness laceration