You are working at Rural General Hospital, solo coverage overnight

 

 

Patient is a 35yo male with no past medical history presents to the ED from home with the complaint of “something in my eye”, he reports blurry vision and severe pain in the right eye.  Visual acuity is grossly intact and his right eye is shown below in the image.  

 

http://www.tedmontgomery.com/the_eye/eyephotos/index.html

 

What is the next step? call ophthalmology?…. Good luck!!

 

The patient pictured above has a metallic foreign body in his eye.  What questions are important to ask and document with these patients?

What were you doing when the injury occurred?  This is important to assess for what type of foreign body has been retained.  Organic material has a higher risk for infection while glass or metal can lead to larger corneal defects.  Velocity of the foreign body is also important to assess for risk of corneal/scleral penetration.  In our patient he was hammering a rusty nail above his head while repairing his barn.

 

What is the exam?  Decreased visual acuity increases risk of central foreign body or penetrating injury.  Slit lamp exam should then be performed to fully assess size and location of object.  Don’t forget to do a full exam including eversion of the eyelids, you don’t want to miss a second foreign body just because you located one.  

 

Fluorescein test?  This can be beneficial to assess if there is a second foreign body under the eyelid.  Looking for vertically oriented linear corneal abrasions seen below (Image 1).  A positive Seidel’s test (seen below, Image 2) could also indicate foreign body puncture and globe penetration.  

     Image 1

Image 2

 

You have now examined the patient and determined they have a metallic foreign body with rust ring, what is your next step in management?  

First provide analgesia with topical anesthesia, remove foreign body with slit lamp as seen below. Give topic antibiotic and close optho follow up.  No not wear contacts until cleared by ophthalmologist.  

accessemergencymedicine.mhmedical.com

To patch or not to patch? There is no evidence that eye patches are beneficial.  Then may even cause harm as patients are unable to tell if their visual acuity is worsening.  

 

What to do with the rust ring?

While removal of the foreign body must be done acutely, removal of the rust ring can be done within 24 hours.  So it is reasonable, if you don’t feel comfortable with the procedure, to send them for outpatient follow up.  Make sure when you do this you are in contact with your consulting ophthalmologist so they can be seen the next day.  

See video for actual procedure: https://www.youtube.com/watch?v=5amf_pNAAyQ

 

Sources:

https://lifeinthefastlane.com/ophthalmology-befuddler-010/

http://accessemergencymedicine.mhmedical.com/ViewLarge.aspx?figid=45356185&gbosContainerID=null&gbosid=null