3.2 Foreign Body, Conjunctival

Date of last review: Due to be updated

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 Fusidic 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