Intraocular Foreign Bodies

Ovid: 5-Minute Sports Medicine Consult, The

Intraocular Foreign Bodies
Kevin N. Waninger
  • The presentation, outcome, and prognosis of intraocular foreign bodies (IOFBs) are variable.
  • Adults: Often in industrial accidents (hammering, metal on metal contact, blast injury, high-speed machines like drills, grinding wheels, saws, windy weather)
  • Children: Often with explosives, weapons, windy weather
  • Similar to most other traumatic injuries, the peak incidence is found in the 2nd and 3rd decades and generally in males younger than 40 yrs of age.
  • Mostly accidental work-related injuries, although increasingly related to home and leisure activity accidents
Risk Factors
Protective eyewear of appropriate quality (3 mm of polycarbonate) prevents virtually all injuries from IOFBs (1).
General Prevention
  • Wear appropriate protective eyewear in any situation (sports, construction, workshops, industries) that may lead to a higher risk of particles or objects getting into the eyes.
  • The eyes should not be rubbed while working with wood or metal pieces. If a foreign body should enter an eye, no attempt should be made by the patient to remove the foreign body if perforation is suspected. If perforation is not suspected, eye irrigation may be attempted to wash out any potential foreign bodies.
  • Use particular caution with explosives.
  • Superficial foreign bodies that are removed after the injury typically leave no permanent sequelae. However, corneal scarring and infection may occur, and the longer the time interval between the eye injury and subsequent treatment, the greater the likelihood that complications may occur.
  • Morbidity greatly increases if the foreign body penetrates into the anterior or posterior chambers, as damage to the iris, lens, and retina can occur and severely affect visual acuity. Any IOFB can lead to infection and endophthalmitis, which can threaten loss of the eye.
Pre Hospital
  • Place a shield over the eye, both eyes if IOFB with globe perforation is suspected.
  • Position patient sitting upright.
  • The activities of the patient and their surroundings at the time of injury are important and should lead to a high index of suspicion for IOFB.
  • Common complaint: “Something flew into my eye”
  • Past medical history should be obtained, including prior surgeries, medications, allergies, tetanus status, last meal (if surgery is a possibility).
  • Visual acuity and correction with contacts (daily- or extended-wear) or glasses
  • Inquire whether the patient was wearing eye protection at the time of injury. Try to find out what type of eyewear, if so, and whether they are still intact.
  • Composition of suspected foreign body is important:
    • Organic: Wood, soil, plants, insect parts
    • Inorganic material: Oxidizes (iron, copper)
    • Inert material: Paint, glass, plastic, fiberglass, nonoxidizing metals, sand
Physical Exam
  • Note that IOFBs can be deceptively subtle on initial presentation. The symptoms of an ocular foreign body may range from irritation to intense, excruciating pain. This is dependent on the location, material, and type of injury.
  • Note that high-speed projectiles may not produce pain or visual acuity problems initially, as the foreign body may be located below the epithelial or conjunctival surface. A fully dilated eye exam may be necessary to visualize all aspects of the eye.
  • Eye pain/foreign body sensation (typically relieved significantly by topical anesthesia)
  • Redness
  • Tearing
  • Blurred/decreased vision
  • Light sensitivity (photophobia)
  • Visible foreign body or rust ring
  • Difficulty opening the eye
  • A complete examination of both eyes is necessary, including visual acuity and fields, lid eversion to check for retained FB, pupil size, shape, and reactivity.
  • Slit lamp, fluorescein, and funduscopic examinations should be performed as soon as possible. Perform intraocular pressures if there is no evidence of perforation.
  • Minimize manipulation of the globe and exercise caution during examination if perforation is suspected to prevent prolapse of ocular contents.
  • Document corneal irregularities, wound location and size, if visible, as well as blood in the anterior chamber or vitreous.
  • Note normal or decreased visual acuity, any conjunctival injection, ciliary injection (especially if an anterior chamber reaction occurs), any visible foreign body, any rust ring (especially if a metallic foreign body has been embedded for at least several hours), any epithelial defect that stains with fluorescein, any corneal edema, and anterior chamber cells/flare.
  • If a corneal infiltrate is present, an infectious cause needs to be considered.
  • Use the Seidel's sign to look for globe penetration that is not so obvious. In the case of a positive Seidel's sign, the oozing aqueous humor at the site of the penetration through the cornea appears under ultraviolet light as a “dark waterfall,” clearing away excess fluorescein on the cornea.
  • Minimize manipulation of the globe and exercise caution during examination to prevent prolapse of ocular contents.
  • Document baseline visual acuity, visual fields, pupillary size, shape and reactivity, corneal irregularities, wound location and size, depth of the anterior chamber, iris and lens condition, blood in the anterior chamber or vitreous, gaze restriction, and external examination.
  • History, physical, and imaging studies should be used to assess number, size, shape, location, composition, visibility, trajectory, and accessibility of the IOFB.
Diagnostic Tests & Interpretation
  • Unless an infectious corneal infiltrate/ulcer or an intraocular foreign body is suspected, no laboratory work is indicated.
  • Infectious corneal infiltrates/ulcers generally require scrapings for smears and cultures.
  • Orbital CT with 0.5-mm axial and coronal cuts
  • Radiographs have low sensitivity for small and nonmetallic objects, but can be used for metallic FBs if CT not available.
  • β-scan US, with caution due to risk of ocular prolapse
  • MRI: Initially contraindicated due to risk of magnetic properties, but may be used to localize small nonmetallic IOFBs after metallic IOFBs ruled out by CT scan
  • Ultrasound biomicroscopy
Differential Diagnosis
  • Corneal abrasion
  • Conjunctival and corneal foreign bodies
  • Corneal perforation
  • Ruptured globe
  • Other trauma without retained IOFB
  • Corneal ulcer
  • Keratitis, bacterial and/or fungal
Ongoing Care
Follow-Up Recommendations
Patient Monitoring
  • Follow up every 1–2 days until the epithelial defect is well healed and corneal infiltrates have resolved.
  • No activity or positioning restrictions are necessary once the wound heals.
  • A gonioscopy should be performed after resolution of the problem. Annual follow-up care for intraocular pressure should be planned if the severity of trauma raises a suspicion for angle-recession glaucoma in later life.
  • A dilated fundus examination should be performed on a routine basis after any injury severe enough to potentially damage the retina.
Patient Education
Eye protection when taking part in risky activities (eg, hammering, mowing the lawn) is strongly recommended.
Prognosis is good unless a rust ring or scarring involves the visual axis. If infection develops, prognosis is more guarded. Globe-penetrating injuries and intraocular foreign bodies have much worse prognoses, but reading vision is usually retained/regained, if properly treated.
  • 930.0 Corneal foreign body
  • 930.1 Foreign body in conjunctival sac
  • 930.2 Foreign body in lacrimal punctum

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