This guideline last updated 06/05/2022 17:45:59

Differential diagnosis

• High velocity particles – risk of globe penetration
• Metallic (ferrous) – rust ring (haemosiderosis)
• Vegetative – risk of fungal infection
• Recurrent erosion syndrome

Possible management by Optometrist

Treatment

• Irrigate eye with normal saline, check pH and refer to ophthalmology immediately if there has been chemical exposure
• Consider risk of ocular perforation (history and signs)
• Consider high velocity injury to the eye and possibility of intraocular foreign body (history)
• Check VA, signs of penetrating injury, pupil responses and dilated fundus examination
• Always refer to ophthalmology if there is:
  
  • Disrupted ocular anatomy
  • Intraocular foreign body
  • Corneal infiltrate
  • Anterior chamber cells
  • Hyphaema
• Rule out multiple particles – cornea, conjunctiva (bulbar, fornix, palpebral):
  • Double evert lids
• Loose foreign body can be irrigated away with normal saline
  • Foreign body on conjunctiva can be removed with a sterile cotton bud
• Corneal foreign body may require removal with a hypodermic needle or other disposable instrument
  • Assess depth of corneal foreign body (slit lamp optical section)
  • Remove foreign body, if superficial, under topical anaesthesia
  • Ensure needle approaches cornea tangentially
  • Rust ring removal
    • Use Alger brush or equivalent to remove rust ring
  • After removal
    • Assess size of remaining epithelial defect so that healing can be monitored
    • Check VA
    • Do not patch eye
• Topical antibiotic and ocular lubrication where corneal epithelium lost
  • Ask if allergic to Chloramphenicol
  • If not, supply Chloramphenicol 1% eye ointment 3 times daily for 5 days
  • If allergic to Chloramphenicol, or pregnant, supply Fucidic acid 1% liquid gel twice a day for 5 days
  • For large epithelial defects, cycloplegia to prevent pupil spasm (e.g. cyclopentolate 1%  3 times daily until healed)
• Refer to local Pharmacist for analgesia for pain relief (Paracetamol or Ibuprofen; dose depends on age)
• PoM Consider a topical NSAID for its analgesic and anti-inflammatory properties, e.g. gutt. diclofenac 0.1% up to four times daily for 1-3 days

Advice

• Consider mechanism of injury and how it can be avoided in the future

Management Category

• Superficial foreign bodies normally not referred
• Always refer to ophthalmology if there is:
  • Deep/intra-corneal foreign body
  • Intraocular foreign body
  • Corneal infiltrate
  • Anterior chamber cells
  • Hyphaema

Possible management by Ophthalmologist

• Exploration of wound (especially if sub-conjunctival haemorrhage is also present)
• Removal of deep foreign body
• Use of burr or other instrument to remove rust ring