Rosen & Barkin's 5-Minute Emergency Medicine Consult (180 page)

TREATMENT

Place a Fox shield and position the patient upright.

Apply topical anesthetic to stop eye discomfort and assist in exam.

• Deep FBs:
  
  • Refer those penetrating the Bowman membrane (next layer under epithelium) to an ophthalmologist, because permanent scarring may occur.
    
• Superficial FBs:
  
  • Irrigation removal technique
    
• Apply topical anesthetic
  
• Try to wash FB off cornea by directing a stream of 0.9% NS at an oblique angle to cornea:
  
  • 25G needle or FB spud removal technique:
    
    • Using slit-lamp to immobilize patient’s head and allow good visualization
      
    • Hold needle (bevel up) with thumb and forefinger, allowing other fingers to be stabilized on the patient’s cheek.
      
    • Lift FB off cornea, keeping needle parallel to corneal surface.
      
• Rust rings removal:
  
  • Within 3 hr, iron-containing FBs oxidize, leaving a rust stain on adjacent epithelial cells.
    
  • Removal recommended as rust rings delay healing and act as an irritant focus
    
  • Remove with needle or pothook burr either at same time as FB or delayed 24 hr
    
• Postremoval therapy:
  
  • Recheck Seidel test to exclude corneal perforation.
    
  • Treat resultant corneal abrasion with antibiotic drops or ointment.
    
  • Initiate cycloplegic agent when suspect presence of keratitis.
    
  • Update tetanus.
    
  • Initiate analgesia (nonsteroidal anti-inflammatory drug [NSAID] or acetaminophen with oxycodone).
    

May require sedation to facilitate exam and FB removal

• Cycloplegics:
  
  • Cyclopentolate 1–2%: 1 drop TID (lasts up to 2 days)
    
  • Homatropine 2% or 5%: 1 drop daily (lasts up to 3 days)
    
• Topical antibiotics for 3 to 5 days: Often used but unproven benefit:
  
  • Erythromycin ointment: Thin strip q6h
    
  • Sulfacetamide 10%: 1 drop q6h
    
  • Ciprofloxacin: 1 drop q6h
    
  • Ofloxacin: 1 drop q6h
    
  • Polymyxin/trimethoprim: 1 drop q6h
    
• Topical NSAIDs:
  
  • Ketorolac: 1 drop q6h
    
  • Diclofenac: 1 drop q6h
    

FOLLOW-UP

Globe penetration

All corneal FBs

• Consult ophthalmologist for:
  
  • Vegetative material removal owing to risk of ulceration
    
  • Any evidence of infection or ulceration
    
  • Multiple FBs
    
  • Incomplete FB removal
    
• Ophthalmology follow-up in 24 hr for:
  
  • Abrasion in the visual field
    
  • Large abrasion
    
  • Abrasions that continue symptomatic or worsen the next day
    
  • Rust ring removal
    

Return or follow-up with a physician if symptoms continue or worsen in 1 or 2 days.

• Consider intraocular FB, especially with history of high-projectile objects or industrial tools.
  
• Clinical evidence does not support eye patching for pain or healing.
  
• After removal, most corneal FBs can be treated as an abrasion and usually do well without further treatment.
  
• Topical anesthetics should not be prescribed for home use.
  

• Ramakrishnan T, Constantinou M, Jhanji V, et al. Corneal metallic foreign body injuries due to suboptimal ocular protection.
  Arch Environ Occup Health
  . 2012;67(1):48–50.
  
• Reddy SC. Superglue injuries of the eye.
  Int J Ophthalmol
  . 2012;5(5):634–637.
  
• Sweet PH 3rd. Occult intraocular trauma: Evaluation of the eye in an austere environment.
  J Emerg Med
  . 2013;44(3):e295–e298.
  
• Walker RA, Adhikari S. Eye emergencies. In: Tintinalli JE, ed.
  Tintinalli’s Emergency Medicine: A comprehensive Study Guide
  . 7th ed. 2011:1517–1549.
  
• Wipperman JL, Dorsch JN. Evaluation and management of corneal abrasions.
  Am Fam Physician
  . 2013;87(2):114–120.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Corneal Abrasion
  
• Red Eye
  

CODES

930.0 Corneal foreign body

BASICS

• A sudden spasmodic contraction of the thoracic cavity resulting in violent release of air from the lungs and usuallyaccompanied by a distinctive sound:
  
  • Deep inspiration
    
  • Glottis closes
    
  • Expiratory muscles contract
    
  • Intrapulmonary pressures increase
    
  • Glottis opens
    
  • Air expiration at high pressure
    
  • Secretion and foreign material excretion
    
  • Vocal cord vibration with tracheobronchial walls, lung parenchyma, and secretions
    
• Defense mechanism to clear the airway of foreign material and secretions:
  
  • Voluntary or involuntary
    
  • Involuntary coughing regulated by the vagal afferent nerves:
    
    • Voluntary coughing under cortical control allowing for inhibition or voluntary cough
      
    • Because of cortical control, placebos can have a profound effect on coughing.
      
  • Reflex involves respiratory tissue receptor activation of afferent neurons to the central cough center followed by efferent output to the respiratory muscles.
    
  • Mechanical receptors in larynx, trachea, and carina sense touch and displacement.
    
  • Chemical receptors in larynx and bronchi are sensitive to gases and fumes.
    
  • Activated by irritants, mucus, edema, pus, and thermal stimuli
    
• Complications of severe coughing:
  
  • Epistaxis
    
  • Subconjunctival hemorrhage
    
  • Syncope
    
  • Pneumothorax
    
  • Pneumomediastinum
    
  • Emesis
    
  • Hernia
    
  • Rectal prolapse
    
  • Incontinence
    
  • Seizures
    
  • Encephalitis
    
  • Intracranial hemorrhage
    
  • Spinal epidural hemorrhage
    
  • Clubbing
    
  • Pruriginous rash
    

• Acute (<3 wk):
  
  • Pneumonia
    
  • Acute bronchitis
    
  • Sinusitis
    
  • Pertussis
    
  • Tuberculosis
    
  • Upper respiratory tract infection
    
  • Cough variant asthma
    
  • COPD exacerbation
    
  • Bronchiectasis
    
  • Pulmonary embolism
    
  • Left ventricular failure
    
  • Airway obstruction (food, pills)
    
  • GERD
    
  • Allergies
    
  • Bronchospasm
    
• Subacute (3–8 wk):
  
  • Postinfectious cough
    
  • Pertussis
    
  • Bronchitis
    
  • Bacterial sinusitis
    
  • Asthma
    
  • GERD
    
  • Pulmonary embolism
    
• Chronic (>8 wk):
  
  • Postnasal drip
    
  • Asthma
    
  • GERD
    
  • Chronic bronchitis
    
  • Tuberculosis
    
  • Bronchiectasis
    
  • Eosinophilic bronchitis
    
  • ACE inhibitor use
    
  • Bronchogenic carcinoma
    
  • Carcinomatosis
    
  • Sarcoidosis
    
  • Left ventricular failure
    
  • Aspiration syndrome
    
  • Psychogenic/habit