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Clinical Procedures > Ophthalmologic Procedures
Foreign Body Removal, Cornea
Article Last Updated: Oct 30, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 13  
Author: Carlos E Cao, MD, MPH, Staff Physician, Emergency Medicine, UCLA Medical Center/Olive-View Medical Center Program
Carlos E. Cao is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Coauthor(s):
Tiffany Sunshine Hackett, MD, MBA, Attending Physician, Cedars Sinai Department of Emergency Medicine, Clinical Instructor of Emergency Medicine, Los Angeles County-University of Southern California Department of Emergency Medicine
Editors: Andrew K Chang, MD, Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Luis M Lovato, MD, Assistant Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center; Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Memorial Community Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
corneal foreign body, corneal fb, ocular foreign body, OFB, intraocular foreign body, IOFB, foreign body removal, eye irrigation, embedded foreign body, embedded intraocular foreign body, eye foreign body, eye injury, penetrating eye injury, superficial eye injury, eye spud, corneal injury, cornea, eye, foreign body, foreign body removal
A corneal foreign body is an object (eg, metal, glass, wood, plastic, sand) either superficially adherent to or embedded in the cornea of the eye. The removal of a corneal foreign body is a procedure commonly performed in the clinic or emergency department setting. If corneal foreign bodies are not removed in a timely manner, they can cause prolonged pain and lead to complications such as infection and ocular necrosis. An intraocular foreign body penetrates into the anterior chamber of the eye or into the globe itself. It is likely to cause significant morbidity and, thus, necessitates a through workup, including, in many instances, a detailed ophthalmologic evaluation with imaging such as plain radiography or CT scan of the orbits. Though MRI is occasionally used, it is contraindicated if a metal foreign body is suspected. The patient’s description of the circumstances of the injury is the most crucial element in determining the likelihood of globe penetration, which would necessitate referral to an ophthalmologist. An intraocular foreign body does not necessarily change visual acuity.
- Foreign body on the cornea
Patients who present to the emergency department with emergent conditions should be referred to an ophthalmologist on the day of presentation. Patients with urgent conditions can be seen the following day.
Emergent conditions - Hyphema (blood in the anterior chamber)
- Diffuse corneal defect or opacity
- Laceration of the cornea or sclera
- Single dilated pupil or an abnormally shaped pupil
- A more deep or shallow anterior chamber (when compared to the other eye)
- Possible penetration of the globe
- Multiple foreign bodies
- Extremely uncooperative patient (eg, young child, intoxicated individual, patient with mental disability)
Urgent conditions
- Instill a topical anesthetic ophthalmic solution (eg, proparacaine 0.5% [Alcaine, Ophthetic]).
- Anesthesia is necessary prior to foreign body removal.
- Anesthesia also usually facilitates the initial eye examination.
- Topical anesthetic ophthalmic solution (eg, proparacaine 0.5% [Alcaine, Ophthetic])
- Fluorescein strips
- Cotton-tipped applicator
- Irrigation fluid with plastic syringe
- Device to remove the foreign body
- Eye spud (specialized equipment designed for the removal of corneal foreign bodies). The tip is less sharp than a needle, so iatrogenic injury is less likely to occur during the procedure.
- A sterile 25-gauge needle, placed onto a syringe (1-3 mm), can be used. Some clinicians like to bend the needle at a slight angle.
- Loupes or a slit lamp
Slit lamp needed for corneal foreign body removal. - Topical antibiotic ophthalmic ointment (eg, erythromycin) or ophthalmic drops (See Pearls section for further discussion.)
- Eye patch (See Pearls section for further discussion.)
Equipment needed for corneal foreign body removal.
- Have the patient press his or her face against the forehead strap and chin rest as demonstrated below so that the patient cannot move his head (and, hence, eye) forward toward the eye spud or needle during removal of the foreign body. This positioning is critically important.
Positioning. - The physician’s hand should be similarly anchored, either against the patient's face or on part of the slit lamp itself. Again, this prevents the physician from inadvertently penetrating the patient's cornea with the spud or needle during the procedure.
- When removing an object from the left eye, place hand on the left maxillary bone.
- When removing an object from the right eye, place hand against the bridge of the nose or the infranasal aspect of the face.
- Explain the procedure, benefits, risks, and complications to the patient or the patient’s representative and obtain informed consent.
- Place 2 drops of anesthetic ophthalmic solution inside the lower eyelid.
Application of anesthetic ophthalmic solution. - Wet the fluorescein strip.
Wetting the fluorescein strip. - Apply a wet fluorescein strip inside the lower eyelid to instill fluorescein onto the cornea. Under ultraviolet light, examine the cornea to locate the foreign body. Document a negative Seidel sign. (A positive Seidel sign indicates corneal penetration with oozing aqueous humor; it appears under ultraviolet light as a "dark waterfall," clearing away excess fluorescein on the cornea.)
Instilling fluorescein onto the cornea. - Inspect the lower eyelid while the patient looks up.
Lower eyelid inspection. - Inspect the upper eyelid by everting with an applicator while the patient looks down. Sweep the recesses of the upper conjunctival fornix.
Upper eyelid inspection. - If the foreign body is superficial, irrigate the eye to moisten the cornea and attempt to remove the foreign body by using a gentle rolling motion with a wetted cotton-tipped applicator. Take care not apply pressure, which may push the foreign body deeper into the cornea, or scrape, which may create a large corneal abrasion.
Irrigation of eye.
Removal of foreign body with wetted cotton-tipped applicator. - An embedded foreign body cannot be removed with irrigation or with a cotton-tipped applicator.
An embedded foreign body. - An embedded foreign body can be removed by using a gentle flicking motion with an eye spud, if available, or with a 25- or 27-gauge needle. Once dislodged from its embedded position on the cornea, remaining corneal debris can be removed with a wetted cotton-tipped applicator.
Removal of embedded foreign body with needle.
Removal of embedded foreign body. - Document a negative Seidel sign after the foreign body is removed.
- Topical ophthalmic antibiotics: Current practice dictates use to prevent superinfection.
- Ophthalmic antibiotic ointments (eg, bacitracin, ciprofloxacin) have an advantage by functioning as a lubricant.
- Ophthalmic solutions (eg, sulfacetamide, ofloxacin) are easier to apply and, therefore, enhance patient compliance.
- Corticosteroid ophthalmic solutions or ointments should be avoided because they increase the likelihood of superinfection and slow healing.
- Pain control: Topical anesthetics prolong epithelial healing and should never be prescribed for pain relief.
- Opioid analgesic agents (eg, hydrocodone/acetaminophen [Vicodin], oxycodone/acetaminophen [Percocet]) can be used to relieve pain and have been found to allow patients to sleep more comfortably at night.
- Nonsteroidal anti-inflammatory drug (NSAID) ophthalmic solutions (eg, ketorolac) can provide significant pain relief and have not been found to slow healing.
- Patching: The use of patching has been controversial. Most recently, studies have shown that corneal abrasions due to a foreign body are best treated without eye patching. Patients note faster healing, less blurred vision, and even less pain without an eye patch. Add this lack of proven benefit to patient inconvenience, and the only possible reason to use an eye patch is to protect abrasions that cover greater than 50% of the cornea.
- Seidel sign: Use the Seidel test to look for hidden globe penetration when it is not obvious. In the case of a positive Seidel sign, the oozing aqueous humor at the site of penetration through the cornea appears under ultraviolet light as a "dark waterfall," clearing away excess fluorescein on the cornea.
- A positive Seidel sign indicates globe penetration and requires emergent ophthalmological consultation.
- Documenting a negative Seidel sign after the removal of a corneal foreign body is good practice, especially after using a sharp instrument, to confirm that no iatrogenic penetration of the cornea occurred during the procedure.
- Incomplete foreign body removal or rust ring
- Conjunctivitis
- Perforation of the cornea
- Epithelial injury
Thanks to Ryan B Viets for being the volunteer for the images.
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Equipment needed for corneal foreign body removal. |
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Slit lamp needed for corneal foreign body removal. |
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| Media file 9:
Removal of foreign body with wetted cotton-tipped applicator. |
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- Reichman EF, Simon RR. Emergency Medicine Procedures. Columbus, OH: McGraw-Hill; 2003.
- Roberts JR, Hedges RJ. Ophthalmologic procedures. In: Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004:1089-118.
Foreign Body Removal, Cornea excerpt Article Last Updated: Oct 30, 2007
Topic originally published: Oct 30, 2007
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