History of Present Illness: A 41-year-old man presents with pain and a foreign body sensation in the right eye since welding 4 days ago. The patient wore eye protective gear; however, he explains that he only wore sunglasses. A spark flew in from above his glasses and hit him in the right eye. The pain has been steady since. He complains of irritation exacerbated by blinking, but vision has remained unchanged. He has no other injury and no other physical complaint.
General Appearance: Patient is alert, awake, comfortable and in no distress
Vitals: Temp: 98 F; Pulse: 71; BP: 133/72; Pulse ox: 98%
HEENT: No facial swelling, erythema, or facial blisters
Visual Acuity : Left eye: 20/20, right eye: 20/25, both eyes 20/20
Pupils: PERLA, no pain with direct or consensual pupillary light response, no tenderness with EOM
Lid Eversion: No foreign body
Slit Lamp Exam:
- Right eye has a corneal foreign body, inferolateral to right pupil, and superficial to the anterior chamber
- Clear cornea with no involvement of the anterior chamber (no hyphema specifically)
- Moderate injection of the right conjunctiva
- Fluorescein exam: No corneal uptake or Seidel’s sign
CT orbits with contrast: The globes have a normal symmetric contour. Preseptal soft tissues and lacrimal glands appear normal. Retro-orbital fat, optic nerves, and extraocular muscles appear normal. No radiopaque foreign body material is seen. No acute fracture or dislocation is seen. There is minimal ethmoid sinus mucosal thickening present. The visible brain parenchyma appears normal.
IMPRESSION: Unremarkable CT scan of the orbits
In the image above, the embedded metal object has already started to develop a rust ring. Seeping rust permanently stains the cornea and has the potential to obstruct vision.
Removal of the corneal foreign body
One approach: Apply tetracaine anesthetic to the affected eye. Under the slit lamp 10x view and using a thin 25 gauge needle, remove the embedded foreign body. [Read another ALiEM post featuring a corneal foreign body removal video.]
Take Home Points
- Foreign bodies from welding embedded in the cornea necessitate prompt intervention.
- Don’t forget the basics:
- Proper eye exam with fluorescein to rule out globe rupture
- Tetanus prophylaxis
- Topical antibiotics (ex: tobramycin + dexamethasone)
- Dislodgment under slit lamp magnified view with prompt ophthalmology follow up