Welcome to question of the day #198

Eyetools question of the day #198

Over my career, I’ve had about six people present in practice complaining of an eye being uncomfortable with a feeling that something was in the eye.

On slit-lamp examination I found an isolated piece of debris stuck in the corneal endothelium which I was able to remove using a cotton swab after having instilled an ocular anaesthetic. This drug makes the eye feel much better for the patient so they are happy but it also allows you to touch the cornea with the cotton swab and to try and dislodge the foreign body, attach it to the fibres of the cotton and then remove it from the eye. I checked the corneal damage using fluorescein and the blue light on my slit lamp and on two occasions felt it was necessary to provide the patient with chloramphenicol (antibiotic) eye drops for use over the next hours and to prevent opportunistic bacterial infection with a review the next day.

When I observed in an accident and emergency department during my training I saw ophthalmologists, use green needles to dig out stubborn particles that were too deep for retrieval using a cotton swab. In other cases, I saw use of a corneal burr. A battery-powered, handheld and low torque motorised burr. It has been designed to remove foreign bodies from the cornea or sclera of patients. This is like a drill that spins and can be used to remove corneal foreign bodies and/or smooth over the damaged corneal endothelium once the debris has been removed. In these cases, antibiotic eye drops or creams were always advised and in some cases an eye bandage.

For your patient, if you have a slit lamp see if the foreign body is superficial enough for you to remove the foreign body with a cotton swab. If you don’t have a slit lamp or can’t remove the debris advise the patient to go immediately to a local accident and emergency department. From the history, the chance of there being a penetrative foreign body is zero. If the history indicates the possibility of a penetrating foreign body, especially a metallic one, again advise going to an accident and emergency department.

If you can remove the foreign body check for staining using fluorescein and blue light and check for a rust ring. Measure visual acuity and note your actions and findings in the clinical records. If there is a rust ring then this must be removed and an ophthalmologist has to do this.

If there is no rust ring and you are licensed to supply antibiotic eye drops or cream then do so and review the next day with the caveat of telling the patient to come back or go to accident and emergency if the eye should worsen. If you can’t prescribe antibiotics advise the patient to purchase some from a pharmacist or obtain a prescription from their general practitioner.

Do the best you can for your patient but know the limits of your skills and equipment and don’t hesitate to seek the help of another eye specialist.