CORNEAL FB

Foreign bodies are one of the most frequent causes of visits for ophthalmic
emergencies. ometimes! the foreign bod" ma" not be present at the time of
e#amination! having left the residual corneal abrasion $ith resultant pain.
uperficial corneal foreign bodies are much more common than deepl" embedded
corneal foreign bodies. %he possibilit" of an intraocular foreign bod" must al$a"s be
considered $hen a patient presents $ith a histor" of trauma.
&n ma'or league baseball! (() of all e"e in'uries are corneal abrasions* in the National
Bas+etball Association! corneal abrasions account for ,-) of all e"e traumas.
International
No difference in frequenc" is observed internationall".
Mortality/Morbidity
.enerall"! superficial foreign bodies that are removed soon after the in'ur" leave no
permanent sequelae. /o$ever! corneal scarring or infection ma" occur. %he longer the
time interval bet$een the in'ur" and treatment! the greater the li+elihood of
complications.
&f the foreign bod" full" penetrates into the anterior or posterior chambers! then it is
officiall" an intraocular foreign bod". &n this case! e"e morbidit" is much more
common. 0amage to the iris! lens! and retina can occur and severel" damage vision.
An" intraocular foreign bod" can lead to infection and endophthalmitis! a serious
condition possibl" leading to loss of the e"e.
Sex
imilar to other traumatic in'uries! the incidence in males is much higher than in
females.
Age
imilar to most other traumatic in'uries! the pea+ incidence is found in the second
decade and generall" occurs in people "ounger than 12 "ears.
History
%he activities of the patient and their surroundings are important. %he time and the
place of the in'ur"! along $ith e#actl" ho$ it occurred! are important. For e#ample! a
patient $ho $as $or+ing $ith a high3speed grinding machine is li+el" to have an
intraocular foreign bod" that ma" be occult in nature! $hereas a patient $ho $as
$or+ing underneath a car $hen rust fell gentl" on the e"e is li+el" to have onl" an
e#ternal in'ur".
4atients ma" complain of the follo$ing5
4ain 6t"picall" relieved significantl" $ith topical anesthesia7
Foreign bod" sensation 6t"picall" relieved significantl" $ith topical anesthesia7
4hotophobia
%earing
Red e"e
Physical
4atients ma" present $ith the follo$ing5
Normal or decreased visual acuit"
Con'unctival in'ection
Ciliar" in'ection! especiall" if an anterior chamber reaction occurs
8isible foreign bod"
Rust ring! especiall" if a metallic foreign bod" has been embedded for hours to da"s
Epithelial defect that stains $ith fluorescein
Corneal edema
Anterior chamber cell9flare
%he patients ma" be as"mptomatic if the foreign bod" is belo$ the
epithelial or con'unctival surface. Over a period of a fe$ da"s! epithelium often
gro$s over small corneal foreign bodies! $ith a resultant reduction in pain.
&f a corneal infiltrate is present! an infectious cause needs to be
considered. Foreign bodies can cause a small sterile inflammator" reaction
around the foreign ob'ect. /o$ever! if a large infiltrate! an" corneal ulceration! a
significant anterior chamber reaction! or significant pain is present! it should be
managed as an infection. ee :eratitis! Bacterial.
Causes
Corneal foreign bod" in'ur" can occur 'ust about an"$here. %he" commonl" occur both
at home and at $or+.
.enerall"! the cause is accidental trauma. %he t"pe of trauma helps to determine the
li+elihood of a superficial versus a deep or even intraocular foreign bod".
;aterials include small pieces of $ood! metal! plastic! or sand.
%he in'ur" usuall" occurs in $ind" $eather or $hen $or+ing $ith po$er tools. 0irt!
sand! or small portions of leaves frequentl" are blo$n into the e"e and adhere to the
superficial cornea.
Differential Diagnoses
Corneal Abrasion
Foreign Bod"! &ntraocular
:eratitis! Bacterial
:eratitis! Fungal
Laboratory Studies
<nless an infectious corneal infiltrate9ulcer or an intraocular foreign bod"
is suspected! no laborator" $or+ is indicated.
&nfectious corneal infiltrates9ulcers generall" require scrapings for smears
and cultures.
Imaging Studies
%o e#clude intraocular or intraorbital foreign bod"! consider B3scan
ultrasound! orbital C% scan 6,3mm a#ial and coronal cuts7! and9or ultrasound
biomicroscop" 6<B;7. &f the foreign bod" is metallic! the initial stud" ma" include
orbital #3ra" films. &f plain films are negative and a high suspicion still e#ists for
intraocular foreign bod"! the previousl" mentioned studies are indicated. %hese
studies should be complemented b" a full3dilated e#amination b" an
ophthalmologist.
Avoid ;R& if a possible histor" of metallic foreign bod" e#ists.
<B;! $ith high3frequenc" ultrasound! is often useful to rule out a foreign
bod" embedded in the anterior sclera. %hese foreign bodies ma" not be visible
because of their nature 6eg! glass7 or overl"ing opacit" 6eg! con'unctival
hemorrhage7.
Other ests
A eidel test is performed to rule out corneal perforation in the setting of a
deep corneal foreign bod".
%he lo$er and upper lids need to be everted to loo+ for additional foreign
bodies. &f a superficial foreign bod" is suspected but not found! double eversion
of the upper lid to search for a foreign bod" is required.
Procedures
Corneal foreign bodies are removed using a sterile foreign bod" spud or
needle after topical anesthesia. Antibiotic is applied to the e"e before and after
the removal. Cotton3tipped applicators often are not appropriate because of the
large surface area of cotton that touches the cornea! potentiall" creating a large
epithelial defect. Because of the ris+ of corneal scarring and inadvertent globe
perforation! this procedure should be completed using a slit lamp biomicroscope
and performed b" a clinician $ho is $ell trained and e#perienced in corneal
foreign bod" removal.
Rust rings that remain in the cornea after removal of a metallic foreign
bod" ma" require removal $ith a rust ring drill. %his procedure also should be
performed using a slit lamp biomicroscope b" a clinician $ho is $ell trained and
e#perienced in rust ring removal because of the ris+ of corneal scarring and
inadvertent globe perforation.
Proceed to reatment ! Management
Medical Care
;anagement ob'ectives include relieving pain! avoiding infection! and preventing
permanent loss of function.
%opical antibiotic drops 6eg! pol"m"#in B sulfate3trimethoprim =4ol"trim>! oflo#acin
=Ocuflo#>! tobram"cin =%obre#> qid7 or ointment 6eg! bacitracin =A:3%racin>!
ciproflo#acin =Cilo#an> qid7 should be prescribed until the epithelial defect heals
to prevent infection.
%opical c"cloplegic 6c"clopentolate ,) qd9bid7 can be considered for pain and
photophobia! although a revie$ of the literature sho$s that the" are not
effective.=,! ->
4ressure patch or bandage contact lens is best avoided 6unless the epithelial defect is
?,2 mm
-
and then bandage contact lens ma" be the better option7.=,! (! 1> %he
follo$ing scenarios represent high ris+ for the patient to develop permanent
vision loss. 0o not patch if an" of the follo$ing are present5
A chance of a perforation of the globe e#ists.
A corneal infiltrate is present.
A chance of a retained intraocular foreign bod" is possible.
Surgical Care
Remove the foreign bod" using irrigation! a sterile needle! or a foreign
bod" removal instrument. 0o not remove if li+elihood of penetration through
more than -@) of the cornea e#ists.
Remove a rust ring $ith an Alger brush or automated burr. Onl" those
clinicians $ho are trained in and regularl" perform this procedure should
complete it.
Consultations
&mmediatel" refer to an ophthalmologist in case of the follo$ing5
/"phema 6blood in the anterior chamber7
0iffuse corneal damage 6focal or diffuse opacit"7
cleral or corneal laceration
Lid edema
0iffuse subcon'unctival hemorrhage
4osttraumatic dilation of pupil or abnormal shape of pupil
Abnormall" shallo$ or deep anterior chamber compared to the fello$ e"e
4ersistent corneal defect or corneal opacit"
An" case $ith possible full penetration of the cornea or sclera
Medication Summary
An uncomplicated case in $hich the foreign bod" is removed can be treated $ith
standard antibiotics. &f a large epithelial defect is present! an antibiotic ointment is
placed prior to the use of a patch. Complicated cases should be seen b" an
ophthalmologist immediatel" and prior to an" therap". For e#ample! if an infiltrate is
present! the ophthalmologist ma" $ant to scrape and plate the lesion before an"
antibiotic is instilled in the e"e.
Antibiotics
Class Summary
4revent infection of an open corneal abrasion.
8ie$ full drug information
Polymyxin " sulfate#trimetho$rim %Polytrim&

For ocular infections! involving cornea or con'unctiva! resulting from strains of
microorganisms susceptible to this antibiotic. Available as a solution and ointment.
%rimethoprim and pol"m"#in B are rarel" sensitiAing! and the" have a $ide spectrum
of action in combination.
.ram3positive5 S aureus, S epidermidis,Streptococcus species 6group A beta3
hemol"tic and nonhemol"tic7! S pneumoniae
.ram3negative5 P aeruginosa, H influenzae, H aegyptius, E coli, K pneumoniae, P
mirabilis 6indole3positive7! Proteus species 6indole3negative7! E aerogenes, C freundii,
C diversus, A calcoaceticus, M lacunata 6some strains7! S marcescens
8ie$ full drug information
obramycin o$hthalmic %obrex&

Li+e other aminogl"cosides! the bactericidal activit" of tobram"cin is accomplished b"
specific inhibition of normal protein s"nthesis in susceptible bacteria! but ver" little
presentl" is +no$n about this action. ;a" inhibit bacterial mRNA s"nthesis! causing
inhibition of bacterial gro$th.
8ie$ full drug information
Ofloxacin o$hthalmic %'loxin&

4"ridine carbo#"lic acid derivative $ith broad3spectrum bactericidal effect.
8ie$ full drug information
Ci$rofloxacin o$hthalmic %Ciloxan&

&nhibits bacterial gro$th b" inhibiting 0NA g"rase.
8ie$ full drug information
"acitracin o$hthalmic %A(#racin) "aciguent&

4revents transfer of mucopeptides into gro$ing cell $all! inhibiting bacterial gro$th.
8ie$ full drug information
*atifloxacin o$hthalmic %+ymar&

Fourth3generation fluoroquinolone ophthalmic indicated for bacterial con'unctivitis.
Elicits a dual mechanism of action b" possessing an B3metho#" group! thereb"
inhibiting the enA"mes 0NA g"rase and topoisomerase &8. 0NA g"rase is involved in
bacterial 0NA replication! transcription! and repair. %opoisomerase &8 is essential in
chromosomal 0NA partitioning during bacterial cell division. &ndicated for bacterial
con'unctivitis due to Corynebacterium propinquum, S aureus, Stapylococcus
epidermidis, Streptococcus mitis, S pneumoniae! or H influenzae.
Cyclo$legics
Class Summary
For comfort of the e"e and to prevent iris adhesion in cases of traumatic iritis.
8ie$ full drug information
Cyclo$entolate HCl ,-.#/0 %Cyclogyl&

C"clopentolate is an anticholinergic agent that induces rela#ation of the sphincter of
the iris and ciliar" muscles. Chen applied topicall" to the e"es! it causes rapid! intense
c"cloplegic and m"driatic effects that reach a pea+ in ,@3D2 min* recover" usuall"
occurs $ithin -1 h. %he c"cloplegic and m"driatic effects are slo$er in onset and
longer in duration in patients $ho have dar+ pigmented irises.
Proceed to 'ollo1#u$
O2er2ie1
A corneal foreign bod" is an ob'ect 6eg! metal! glass! $ood! plastic! sand7 either
superficiall" adherent to or embedded in the cornea of the e"e. %he removal of a
corneal foreign bod" is a procedure commonl" performed in the clinic or emergenc"
department setting.=,> &f corneal foreign bodies are not removed in a timel" manner!
the" can cause prolonged pain and lead to complications such as infection and ocular
necrosis.
An intraocular foreign bod" penetrates into the anterior chamber of the e"e or into the
globe itself. &t is li+el" to cause significant morbidit" and! thus! necessitates a through
$or+up! including! in man" instances! a detailed ophthalmologic evaluation $ith
imaging such as plain radiograph" or C% scan of the orbits.=-> %hough ;R& is
occasionall" used! it is contraindicated if a metal foreign bod" is suspected. %he
patientEs description of the circumstances of the in'ur" is the most crucial element in
determining the li+elihood of globe penetration! $hich $ould necessitate referral to an
ophthalmologist.=(! 1> An intraocular foreign bod" does not necessaril" change visual
acuit".
Indications
Foreign bod" on the cornea
Contraindications
4atients $ho present to the emergenc" department $ith emergent conditions should
be referred to an ophthalmologist on the da" of presentation. 4atients $ith urgent
conditions can be seen the follo$ing da".
3mergent conditions
/"phema 6blood in the anterior chamber7
0iffuse corneal defect or opacit"
Laceration of the cornea or sclera
ingle dilated pupil or an abnormall" shaped pupil
A more deep or shallo$ anterior chamber 6$hen compared to the other
e"e7
4ossible penetration of the globe
;ultiple foreign bodies
E#tremel" uncooperative patient 6eg! "oung child! into#icated individual!
patient $ith mental disabilit"7
4rgent conditions
ignificant lid edema
0iffuse subcon'unctival hemorrhage
Anesthesia
Anesthesia is necessar" prior to foreign bod" removal and usuall"
facilitates the initial e"e e#amination.
&nstill a topical anesthetic ophthalmic solution 6eg! proparacaine 2.@)
=Alcaine! Ophthetic>7.
35ui$ment
%opical anesthetic ophthalmic solution 6eg! proparacaine 2.@) =Alcaine!
Ophthetic>7
Fluorescein strips
Cotton3tipped applicator
&rrigation fluid $ith plastic s"ringe
0evice to remove the foreign bod"
E"e spud 6specialiAed equipment designed for the removal of corneal foreign bodies7.
%he tip is less sharp than a needle! so iatrogenic in'ur" is less li+el" to
occur during the procedure.
A sterile -@3gauge needle! placed onto a s"ringe 6,3( mm7! can be used. ome
clinicians li+e to bend the needle at a slight angle.
Loupes or a slit lamp 6ee image belo$.7
lit lamp needed for corneal foreign bod" removal.
%opical antibiotic ophthalmic ointment 6eg! er"throm"cin7 or ophthalmic
drops 6ee 4earls section for further discussion.7
E"e patch 6ee 4earls section for further discussion. ee image belo$.7
Equipment needed for corneal foreign bod" removal.
Positioning
/ave the patient press his or her face against the forehead strap and chin
rest as demonstrated belo$ so that the patient cannot move his head 6and!
hence! e"e7 for$ard to$ard the e"e spud or needle during removal of the
foreign bod". %his positioning is criticall" important.
4ositioning.
%he clinicianEs hand should be similarl" anchored! either against the
patientFs face or on part of the slit lamp itself. Again! this prevents the clinician
from inadvertentl" penetrating the patientFs cornea $ith the spud or needle
during the procedure.
Chen removing an ob'ect from the left e"e! place hand on the left
ma#illar" bone.
Chen removing an ob'ect from the right e"e! place hand against the
bridge of the nose or the infranasal aspect of the face.
echni5ue
E#plain the procedure! benefits! ris+s! and complications to the patient or
the patientEs representative and obtain informed consent.
4lace - drops of anesthetic ophthalmic solution inside the lo$er e"elid.
ee image belo$.
Application of anesthetic ophthalmic solution.
Cet the fluorescein strip. ee image belo$.
Cetting the fluorescein strip.
Appl" a $et fluorescein strip inside the lo$er e"elid to instill fluorescein
onto the cornea. <nder ultraviolet light! e#amine the cornea to locate the foreign
bod". 0ocument a negative eidel sign. 6A positive eidel sign indicates corneal
penetration $ith ooAing aqueous humor* it appears under ultraviolet light as a
Gdar+ $aterfall!G clearing a$a" e#cess fluorescein on the cornea.7 ee image
belo$.
&nstilling fluorescein onto the cornea.
&nspect the lo$er e"elid $hile the patient loo+s up. ee image belo$.
Lo$er e"elid inspection.
&nspect the upper e"elid b" everting $ith an applicator $hile the patient
loo+s do$n. $eep the recesses of the upper con'unctival forni#. ee image
belo$.
<pper e"elid inspection.
&f the foreign bod" is superficial! irrigate the e"e to moisten the cornea and
attempt to remove the foreign bod" b" using a gentle rolling motion $ith a
$etted cotton3tipped applicator. %a+e care not to appl" pressure! $hich ma"
push the foreign bod" deeper into the cornea! or scrape! $hich ma" create a
large corneal abrasion. ee images belo$.
&rrigation of e"e.
Removal of foreign bod" $ith $etted cotton3tipped applicator.
An embedded foreign bod" cannot be removed $ith irrigation or $ith a
cotton3tipped applicator. ee image belo$.
An embedded foreign bod".
An embedded foreign bod" can be removed b" using a gentle flic+ing
motion $ith an e"e spud! if available! or $ith a -@3 or -H3gauge needle. 4lace
the hub of the needle on the tip of a cotton s$ab or a (3mL s"ringe. Approach
the cornea from the side! $ith the needle in a plane tangent to the cornea and
the bevel a$a" from the corneal surface. %his minimiAes the chance of corneal
perforation. Once dislodged from its embedded position on the cornea!
remaining corneal debris can be removed $ith a $etted cotton3tipped applicator.
ee images belo$.
Removal of embedded foreign bod" $ith needle.
Removal of embedded foreign bod".
0ocument a negative eidel sign after the foreign bod" is removed.
Pearls
%opical ophthalmic antibiotics5 Current practice dictates use to prevent
superinfection.=@>
Ophthalmic antibiotic ointments 6eg! bacitracin! ciproflo#acin7 have an advantage b"
functioning as a lubricant.
Ophthalmic solutions 6eg! sulfacetamide! oflo#acin7 are easier to appl" and! therefore!
enhance patient compliance.
Corticosteroid ophthalmic solutions or ointments should be avoided because the"
increase the li+elihood of superinfection and slo$ healing.
4ain control5 %opical anesthetics prolong epithelial healing and should
never be prescribed for pain relief.
Opioid analgesic agents 6eg! h"drocodone9acetaminophen =8icodin>!
o#"codone9acetaminophen =4ercocet>7 can be used to relieve pain and
have been found to allo$ patients to sleep more comfortabl" at night.
Nonsteroidal anti3inflammator" drug 6NA&07 ophthalmic solutions 6eg! +etorolac7 can
provide significant pain relief and have not been found to slo$ healing.=D>
4atching5 %he use of patching has been controversial. ;ost recentl"!
studies have sho$n that corneal abrasions due to a foreign bod" are best
treated $ithout e"e patching.=H! B! I> 4atients note faster healing! less blurred
vision! and even less pain $ithout an e"e patch. Add this lac+ of proven benefit
to patient inconvenience! and the onl" possible reason to use an e"e patch is to
protect abrasions that cover greater than @2) of the cornea.
eidel sign5 <se the eidel test to loo+ for hidden globe penetration $hen
it is not obvious.=,2> &n the case of a positive eidel sign! the ooAing aqueous
humor at the site of penetration through the cornea appears under ultraviolet
light as a Gdar+ $aterfall!G clearing a$a" e#cess fluorescein on the cornea.
A positive eidel sign indicates globe penetration and requires emergent
ophthalmological consultation.
0ocumenting a negative eidel sign after the removal of a corneal foreign bod" is
good practice! especiall" after using a sharp instrument! to confirm that no
iatrogenic penetration of the cornea occurred during the procedure.
Com$lications
&ncomplete foreign bod" removal or rust ring
Con'unctivitis
4erforation of the cornea
Epithelial in'ur"
'urther In$atient Care
Foreign bodies that present an" potential for intraocular penetration must
b" e#plored in the operating room. %hese in'uries should be e#plored $ithin -1
hours of initial e#amination.
'urther Out$atient Care
Follo$ up ever" - da"s until the epithelial defect is $ell healed and an"
corneal infiltrates have resolved.
4erform a gonioscop" after the resolution of the problem! and consider
annual follo$3up care for intraocular pressure if the severit" of trauma raises a
suspicion for angle3recession glaucoma in later life.
A dilated fundus e#amination should be performed on a routine basis after
an" in'ur" severe enough to potentiall" damage the retina.
Deterrence/Pre2ention
Cear safet" goggles in an" situation 6eg! sports! construction! $or+shops!
industr"7 that has a high ris+ of particles or ob'ects fl"ing into the e"es.
Com$lications
Rust ring usuall" is due to an iron foreign bod" and can be removed
carefull" at a slit lamp using a burr.
&nfectious +eratitis is common in organic in'uries and in neglected cases. &t
ma" need to be scraped for smears and cultures. &t needs to be treated
aggressivel" $ith topical antibiotics. &f ulceration is unresponsive to antibiotics!
consider using riboflavin cross3lin+ing as one stud" has suggested.=@>
.lobe perforation occurs in metal3on3metal and similar high3speed t"pe
in'uries. &t also can occur if a corneal ulcer is neglected. &t requires surgical
repair.
Prognosis
.ood prognosis e#ists unless a rust ring or scarring involves the visual
a#is. &f infection develops! prognosis is more guarded. .lobe penetrating in'uries
and intraocular foreign bodies are separate categories and have much $orse
prognoses.
Patient 3ducation
Remind patients of the importance of $earing protective e"e$ear in an"
high3ris+ situation.
E"es should not be rubbed $hile $or+ing $ith $ood or metal pieces.
&f a foreign bod" enters the e"e! the e"e should not be rubbed and no
attempt should be made b" the patient to remove the foreign bod".
For e#cellent patient education resources! visit e;edicineFs E"e and
8ision Center. Also! see e;edicineFs patient education articles E"e &n'uries and
Foreign Bod"! E"e.
&N%RAOC<LAR FB
"ac6ground
&ntraocular foreign bodies 6&OFBs7 are rather variable in presentation! outcome! and
prognosis. Cith increased a$areness and advanced surgical techniques! the outcome
and the prognosis for these potentiall" devastating in'uries have substantiall"
improved.
%he most important limiting factor toda" is the damage occurring at the time of the
initial in'ur". One effective method appears to be proph"lactic chorioretinectom" 6see
urgical Care7! $hich reduces the ris+ of postin'ur" proliferative vitreoretinopath"
648R7.
;etal intraocular foreign bod" located in the left temporal pars plana region seen on a#ial C% scan.
Patho$hysiology
%he final resting place of and damage caused b" an &OFB depend on several factors!
including the siAe! the shape! and the momentum of the ob'ect at the time of impact!
as $ell as the site of ocular penetration.=,! ->
&OFBs transversing the lens are less li+el" to cause ma'or retinal damage* conversel"!
a smaller $ound siAe usuall" means deeper penetration.
&n addition to the initial damage caused at the time of impact! the ris+ of
endophthalmitis and subsequent scarring 6eg! 48R7 pla" an important role in the
planning of the surgical intervention.=(>
3$idemiology
're5uency
4nited States
According to the <nited tates E"e &n'ur" Registr" 6<E&R7! the surveillance arm of
the American ociet" of Ocular %rauma 6AO%7! the frequenc" in the <nited tates is
,D). %he most common cause is hammering* the incidence over time sho$s a
decrease at the $or+place and an increase in the home.=1>
International
%he frequenc" greatl" varies 6up to 1,)7 $orld$ide! depending upon the population
surve"ed.
Mortality/Morbidity
;ost &OFBs cause internal damage! and most $ill come to rest in the posterior
segment. Commonl" in'ured structures include the cornea! the lens! and the retina.
7ace
No racial predilection has been found so far.
Sex
According to the <E&R! I() of patients $ith &OFBs are male.
Age
According to the <E&R! the average patient is aged (, "ears.
Proceed to Clinical Presentation
History
A fe$ direct questions should be sufficient for the ophthalmologist to suspect the
presence of an &OFB in e"es $ith an open globe in'ur".
&n case of doubt! it is advisable to err on the side of an &OFB presence. %he most
common cause for litigation against the ophthalmologist in a trauma case is a missed
&OFB. &t is important to remember that the patient ma" be una$are of an" ob'ect
entering 6or even stri+ing7 the e"e! and the vision ma" be unaffected initiall".
Physical
A complete e#amination of both e"es is necessar"! including the visual acuit".
A corneal entr" $ound and a hole in the iris provide tra'ector" information.
%he slit lamp is e#tremel" useful in detailing all anterior segment pathologies.=@>
%he indirect ophthalmoscope through a dilated pupil ma" allo$ direct visualiAation of
the &OFB! $hich gives the most useful information for the surgeon.
.onioscop" and scleral depression are not recommended unless the entr" $ound has
been surgicall" closed.
Causes
/ammering and using po$er tools are the most important causes. 4rotective e"e$ear!
if appropriate 6( mm of pol"carbonat
Laboratory Studies
Culture an intraocular foreign bod" 6&OFB7 or a sample of vitreous if an
infection is suspected. Remember that a positive result does not mean that an
infection is occurring and that a negative result does not preclude the possibilit"
of endophthalmitis.=D>
Imaging Studies
C% scans are the imaging stud" of choice for &OFB localiAation.
A consultation $ith the C% technician is helpful in selecting the optimal section so as to
reduce the ris+ of a false3negative result.
A helical C% scan is the most efficient method to establish a diagnosis. /elical C%
scans have a ver" high identification rate.
Cith conventional C% scans! cuts of 2.@ mm are advised.
;etal intraocular foreign bod" located in the left temporal pars plana region seen on
a#ial C% scan.
ame metallic intraocular foreign bod" as in previous image! as seen on coronal C%
scan vie$.
4lain #3ra" is useful if a metallic &OFB is present and a C% scan is
unavailable.
;R& is generall" not recommended for metallic &OFBs.
<ltrasound is a useful tool in localiAing &OFBs! and its careful use is
possible even if the globe is still open* alternativel"! intraoperative use after
$ound closure can be attempted. %he ultrasound biomicroscope ma" help $ith
&OFBs in the anterior segment.=H! B>
Other ests
Electroretinograph" is useful if a chronic &OFB is found and siderosis
threatens or is present
Medical Care
"stemic and topical antibiotic therap" ma" be started prior to the surgical
intervention. %opical corticosteroids are also important to minimiAe the inflammation. A
tetanus booster ma" also be appropriate.
Surgical Care
%he timing of intervention is primaril" determined b" $hether the ris+ of
endophthalmitis is high. &f the ris+ is high! immediate 6emergenc"7 surger"! for
intraocular foreign bod" 6&OFB7 removal as $ell as vitrectom" if the &OFB is in the
posterior segment! is indicated.=I> &n most other cases! the surgeon has the option of
deferring intervention for a fe$ da"s to reduce the ris+ of intraoperative hemorrhage.
%he $ound! ho$ever! should be closed as soon as possible. A stud" b" Jhang et al
e#amined ,1-, e"es in ,@ hospitals in China over @ "ears and concluded that closing
the primar" $ound $ithin -1 hours! $hether b" repair or independent self3sealing!
reduces the endophthalmitis ris+.=,2> &f endophthalmitis occurs! it is present at the time
of patient presentation in over I2) of the cases.=,,! ,->
&OFBs in the anterior chamber are t"picall" removed through a paracentesis 6not
through the original $ound7 performed at I23,B2K from $here the &OFB is
located. 8iscoelastics should be used to reduce the ris+ of iatrogenic damage to
the corneal endothelium and the lens.
An intralenticular &OFB does not necessaril" cause cataract. <nless there is a ris+ of
siderosis or the loss to follo$3up is high! the &OFB and the lens ma" be left in
situ. Other$ise! usuall"! the &OFB is e#tracted first! the lens is e#tracted second!
and an intraocular lens 6&OL7 is implanted simultaneousl".=,(>
A posterior segment &OFB requires a vitrectom"! unless the tissue damage is minimal.
%he posterior h"aloid should al$a"s be removed! and an" deep impact should
be proph"lacticall" treated. For the actual removal! the best tool to e#tract a
ferrous &OFB is a strong intraocular magnet. For nonmagnetic &OFBs! a proper
forceps or a lasso ma" be used. E#ternal electromagnets should not be used
since the" do not allo$ controlled e#traction.=,1! ,@! ,D! ,H>
Rarel"! a scleral cut3do$n is used.
&f the &OFB has caused a deep impact 6ie! involving the choroid7! proph"lactic
chorioretinectom" is recommended. <sing the highest setting of the diatherm"
machine! the probe is used to destro" the retina and the choroid around the impact
site! thereb" leaving a bare sclera to surround the impact site.=,B> &n earl" clinical tests!
this procedure has proven to be ver" effective in the prevention of the development of
both proliferative vitreoretinopath" 648R7 and radiating retinal folds.
Acti2ity
No activit" restriction is necessar" once the $ound heals and there is no
need for positioning.
Medication Summary
%he goal of pharmacotherap" is to reduce morbidit" and to prevent complications!
such as posterior s"nechia 6pupillar" dilation7! inflammation 6corticosteroids7! and
intraocular pressure 6&O47 elevation.
Antibiotics
Class Summary
For use in ever" case 6s"stemic and topical7* intravitreal usuall" onl" if infection is
present or the case is high ris+.
8ie$ full drug information
8ancomycin %8ancocin) 8ancoled) Ly$hocin&

0OC for gram3positive coverage. 4otent antibiotic directed against gram3positive
organisms and active against Enterococcus species. <seful in the treatment of
septicemia and s+in structure infections. &ndicated for patients $ho cannot receive! or
have failed to respond to penicillins and cephalosporins! or have infections $ith
resistant staph"lococci. For abdominal penetrating in'uries! it is combined $ith an
agent active against enteric flora and9or anaerobes.
%o avoid to#icit"! current recommendation is to assa" vancom"cin trough levels after
third dose dra$n 2.@ h prior to ne#t dosing. <se creatinine clearance to ad'ust dose in
patients diagnosed $ith renal impairment.
<sed in con'unction $ith gentamicin for proph"la#is in penicillin3allergic patients
undergoing gastrointestinal or genitourinar" procedures.
8ie$ full drug information
Cefta9idime %Ce$ta9) 'orta9) a9icef) a9idime&

First3line choice for intravitreal gram3negative coverage. %hird3generation
cephalosporin $ith broad3spectrum! gram3negative activit"* lo$er efficac" against
gram3positive organisms* higher efficac" against resistant organisms. Arrests bacterial
gro$th b" binding to one or more penicillin3binding proteins.
Antifungals
Class Summary
%heir mechanism of action ma" involve an alteration of RNA and 0NA metabolism or
an intracellular accumulation of pero#ide that is to#ic to the fungal cell.
8ie$ full drug information
Am$hotericin " %Am$hocin) 'ungi9one&

4roduced b" a strain of Streptomyces nodosus* can be fungistatic or fungicidal. Binds
to sterols! such as ergosterol! in the fungal cell membrane! causing intracellular
components to lea+ $ith subsequent fungal cell death.
Proceed to 'ollo1#u$
'urther In$atient Care
<nless serious complications are present! the patient can be discharged
shortl" after surger".
Educate the patient about the potential of both earl" complications 6eg!
intraocular pressure elevation7 and late complications 6eg! scarring7.
'urther Out$atient Care
Follo$3up visits are necessar" for at least 1 months to determine $hether
proliferative vitreoretinopath" has occurred. Rehabilitation service ma" be
necessar" if permanent visual impairment is present.
In$atient ! Out$atient Medications
%opical antibiotics and corticosteroids in the earl" postoperative period are
indicated.
Deterrence/Pre2ention
afet" e"e$ear made of pol"carbonate 6( mm in thic+ness7 virtuall"
eliminates the ris+ of intraocular foreign bodies 6&OFBs7.
Com$lications
Endophthalmitis! corneal scarring! elevated intraocular pressure! cataract!
retinal detachment! proliferative vitreoretinopath"! and metallosis 6eg! chalcosis!
siderosis7 are possible complications.=,I>
Prognosis
%he prognosis is generall" relativel" good. Over one half of e"es $ith
&OFB in'ur" regain9retain reading vision.
Patient 3ducation
E"e protection $hen parta+ing in ris+" activities 6eg! hammering! mo$ing
the la$n7 is strongl" recommended.=-2>