After foreign body removal, consider steroid, cycloplegic, antibiotic, disposable lens

Issue: July 2001

Cycloplegic, antibiotic, NSAID, disposable lens

Leonid Skorin Jr., OD, DO, FAAO, FAOCO: Over the years, the traditional strategy for managing traumatic corneal abrasions as well as abrasions following foreign body removal included a cycloplegic agent, broad-spectrum antibiotic and a pressure patch. Unfortunately, this method has several disadvantages:

the practitioner is unable to apply more cycloplegic or antibiotic after the patch is applied;
the patient is rendered monocular, affecting the ability to drive and work;
the patient may develop an allergy to the tape used to apply the patch;
this method cannot be used in one-eyed individuals or if both eyes have abrasions; and
the patient has persistent discomfort, and loosening of the patch leads to the patient removing the eye pad before the next office visit.

With the release of topical nonsteroidal anti-inflammatory drugs such as Acular (0.5% ketorolac, Allergan) and Voltaren (0.1% diclofenac, Novartis Ophthalmics) and the availability of inexpensive disposable contact lenses, a new approach to this problem emerged in the mid-1990s. At that time, several studies showed that pressure patching may be supplanted in certain cases of corneal abrasion and foreign body removal.

Today’s approach in such cases includes the use of a short-acting cycloplegic agent such as Cyclogyl (1% cyclopentolate, Alcon) or 5% homatropine three times a day to relieve any ciliary spasm or secondary traumatic iritis; a broad-spectrum topical antibiotic such as Polytrim (polymyxin B sulfate/trimethoprim sulfate, Allergan) or Ocuflox (0.3% ofloxacin, Allergan) four times a day to prevent secondary microbial keratitis; and a topical nonsteroidal anti-inflammatory agent four time a day to inhibit prostaglandin production.

Prostaglandins mediate the signs of inflammation and pain. This combination of medication with the use of a disposable contact lens for therapeutic purposes often leads to faster healing, significantly less pain and discomfort and allows the patient to return to normal activities more quickly.

Whether the patient is patched or not, some individuals require additional oral pain medications. Use over-the-counter drugs when possible and prescribe generic equivalents when available.

Leonid Skorin Jr., OD, DO, FAAO, FAOCO, practices in Albert Lea, Minn., and writes and lectures on ocular disease and neuro-ophthalmic disorders. He underwent fellowship training in neuro-ophthalmology. He may be reached at the Albert Lea Eye Clinic, Mayo Health Systems, 1206 W. Front St., Albert Lea, MN 56007; (507) 373-8214; fax: (507) 373-2819; e-mail: skorin.leonid@mayo.edu. Dr. Skorin has no direct financial interest in the products mentioned above, nor is he a paid consultant for any companies mentioned.

Antibiotic, steroid, 1-day follow-up

Russell Laverty, OD, FAAO: Fluorescein should first be instilled to determine if Seidel’s sign is present. Visual acuity should be taken to establish a baseline. After instilling Ophthaine (proparacaine, Apothecon), remove the foreign body with either a corneal spud or alger brush, or both.

Prescribe Tobradex (tobramycin/dexamethasone, Alcon) four times daily for 4 days. If the patient experiences greater than moderate pain, apply a bandage lens for 1 day. No nonsteroidal anti-inflammatory drug (NSAID) need be prescribed, because pain would be minimal with a bandage contact lens. Check for cells in the anterior chamber. I normally do not provide a bandage lens, nor pressure patch, but I instruct the patient to return the next day.

Most of my patients do not wear a bandage contact lens. I do not recommend a topical NSAID, but will prescribe a combination antibiotic steroid. I may prescribe an oral pain medication such as Vicodin (500 mg acetaminophen/5 mg hydrocodone bitartrate, Knoll) three times daily for 1 day. Most often, 500 mg of Tylenol (acetaminophen, McNeil) three times daily is sufficient.

If pain is moderate, I will instill a drop of homatropine 5% in the office for a cycloplegic effect.

Russell Laverty, OD, FAAO, is in private practice in Midwest City, Okla. He can be reached at Heritage Park Vision Source, 6912 E. Reno, Ste. 101, Midwest City, OK 73110; (405) 732-2277; fax: (405) 737-4776. Dr. Laverty has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Bandage lens, NSAIDs, 1-day follow-up

Paul M. Dobies, OD, FAAO: It depends on the size of the corneal defect, the location of the defect, the type and amount of the foreign body and the symptoms I might expect the patient to experience after its removal. Most foreign bodies are quite small, minimally embedded in the corneal epithelium and easily removed.

The more central the defect, the more discomfort the patient might experience after the topical anesthetic wears off. Having used a topical antibiotic in addition to the topical anesthetic before removing the foreign body, I might consider a topical nonsteroidal anti-inflammatory drug (NSAID) and a bandage lens with follow-up in 24 hours for more central and larger residual corneal defects. For more peripheral smaller residual corneal defects, I might consider a topical NSAID, no bandage lens or patch and nonpreserved artificial tears every hour or two with follow-up in 24 hours.

Patients sometimes experience intense pain from foreign bodies that, when removed, leave large central or peripheral defects. Once the large offending foreign body is removed (for example, burning embers, windblown sand, some non-alkali substances, etc.), a 24-hour pressure patch with antibiotic ointment and possibly an oral analgesic (Vicodin, Tylenol with Codeine [McNeil], Ultram [tramadol, Ortho-McNeil], NSAIDs, assuming no contraindications) might be considered. Additionally, a half surgical-strength drop of Betadine can be used off label to sterilize the ocular surface before pressure patching depending upon the potential for post-removal infection.

Finally, remember that neomycin has some anti-fungal properties and can be used for “eye vs. tree/bush/plant” foreign bodies and injuries. The relatively small probability of contact dermatitis caused by neomycin is much easier to treat than the relatively small probability of a residual fungal corneal ulcer.

Paul M. Dobies, OD, FAAO, is an assistant professor at Southern California College of Optometry, 2575 Yorba Linda Blvd., Fullerton CA 92831; (714) 992-7814; fax: (714) 992-7811; e-mail: pdobies@scco.edu. Dr. Dobies has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.