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Consider infection prevention, pain relief in patients with foreign objects
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---Foreign bodies can consist of metal, glass, plastic, concrete, grass and dirt. This metallic foreign body resulted from hammering a nail. The foreign body should be removed and patients should be treated for pain and prevention of infection.
Ocular foreign bodies can consist of many different materials: metal, glass, plastic, concrete and even grass and dirt. The majority of foreign body cases involve hobbyists or result from on-the-job mishaps.
“In our emergency department, we usually see patients who were working on their homes, cars or yards,” said Kari Blaho, PhD, of the University of Tennessee at Memphis. “Also, we have a big forensics unit, where we care for prisoners and psychiatric patients, so we see a lot of patients who actually stick things in their eyes.”
Topical anesthetic
Dr. Blaho said the initial priority in treating foreign body cases is to apply a topical anesthetic to immediately relieve some of the pain and discomfort the patient is experiencing. This also enables the practitioner to examine the eye, she noted. Once the foreign body is removed, “You might use a cycloplegic, something like homatropine, if they’re really uncomfortable, and then give them some pain medication,” she advised. “As with an abrasion, cycloplegics put the ciliary body at rest and make the patient more comfortable. The eye also stays dilated, and that prompts the patient to seek follow-up.”
As an alternative to using 2% or 5% homatropine, John Nishimoto, OD, of the Southern California College of Optometry recommends using another cycloplegic agent, Cyclogyl 1% (cyclo pentolate HCl, Alcon). “It can be used once a day and will prevent any secondary iritis,” he said, stressing that the medication prescribed depends on the individual case and on the severity of the condition. If you have a more severe case, such as a more traumatic-type injury, you would probably use homatropine because it is stronger.”
Patch only if necessary
If the patient is suffering extreme discomfort, Dr. Blaho said, the practitioner may choose to patch the eye after the foreign body is removed and the eye is treated with an antibiotic or cycloplegic. “If they are experiencing little discomfort after foreign body removal we won’t patch it,” she said.
Dr. Nishimoto agreed that patching should be kept to a minimum and only used in extreme cases. “We usually don’t patch,” he said. “If you patch the eye, you run a higher risk of infection because the foreign bodies are not clean.”
Pain relief
Dr. Nishimoto said that nonsteroidal anti-inflammatory drops may be prescribed for the patient to apply at home to keep the eye comfortable. “Voltaren (diclofenac sodium, Ciba Vision) drops could be used in conjunction with the antibiotic drops, usually four times a day,” he advised.
“The removal process causes a bit of irritation, so the patients might complain of some pain and irritation for about a week. These drops will help relieve some of that irritation,” he added.
Side effects that may result from topical medications include blurred vision and sensitivity to light, especially with the cycloplegic agents that dilate the pupil, Dr. Nishimoto noted. “For the mild cases of foreign bodies that have been removed, if there isn’t much trauma, then we won’t prescribe cycloplegic agents,” he said.
“If there’s been a lot of trauma and we think that the patient may be uncomfortable, we might want to give him or her Cyclogyl. Again, that’s not a hard-and-fast rule; some patients might do just fine when you remove the foreign body,” he added.
Preventing infection
Once the eye has been made comfortable, the doctors recommended prescribing antibiotics to ward off any infection. “With any type of foreign body, the major concern is possible infection,” Dr. Nishimoto said.
He suggested a topical antibiotic such as Polytrim (trimethoprim sulfate, polymyxin B sulfate, Allergan) to prevent any bacterial infection. Dr. Blaho recommended erythromycin ointment on the basis of good antimicrobial coverage and reasonable expense. “A big concern in the emergency department is that the medicine is affordable,” she noted. “Many topical antibiotics are somewhat expensive, but erythromycin ointment has good coverage and you can put it in before you send the patient home.”
The medication may also be easier for patients to use after they get home, she said. “People tend to be less compliant with drops, so an ointment is helpful because it can be used less frequently,” she noted.
Dr. Nishimoto said that oral medications usually are not necessary “unless you have a penetrating injury into the eye. Usually, those cases are referred for surgical removal because those foreign pieces of material are not sterile,” he said. “If they get inside the eye, there’s a risk for infection, which can result in blindness or losing the eye.”
Dr. Blaho said that an oral non steroidal anti-inflammatory drug such as ibuprofen is commonly prescribed by the emergency department for pain. “Or we’ll give a narcotic/nonsteroidal combination, such as Percocet [oxycodone and acetaminophen, DuPont],” she said. “For patients in whom a nonsteroidal anti-inflammatory is contraindicated or if their pain is not adequately managed by the drug, then Percocet should be used. It is inexpensive and is associated with less incidence of nausea and vomiting than other narcotics.”
Next-day follow-up
After the removal and necessary treatment, the patient is sent home with instructions to return the next day for follow-up. “Usually, you have the patient come back the next day to re-check the eye,” Dr. Nishimoto recommended. “After that, if things are going well, the patient will need to return only once more. However, if the patient is not doing well after 1 week of treatment, he or she needs to return. Obviously, if the patient is getting worse, he or she needs to return immediately.”
Dr. Blaho said that appointments are scheduled before patients leave the emergency department. “They’ll be evaluated the next day, and like most abrasions, if they’re not severe, the area where the foreign body has been removed will heal within a day or two,” she said. “They’ll only use the antibiotic until the injury is healed. If they’re still having significant pain after a day or two, then they need to be re-evaluated.”
For Your Information:
- Kari Blaho, PhD, may be reached at the Emergency Medicine Department at the University of Tennessee at Memphis, 842 Jefferson Ave., A645, Memphis, TN 38103; (901) 545-8699; fax: (901) 545-8996. Dr. Blaho has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.
- John Nishimoto, OD, can be reached at the Southern California College of Optometry, 2575 Yorba Linda Blvd., Fullerton, CA 92831-1699; (714) 449-7401; fax: (714) 992-7809. Dr. Nishimoto has no direct financial interest in the products mentioned in this story, nor is he a a paid consultant for any companies mentioned.