The most common eye injury encountered in family practice is a foreign body in the eye. The most common causes of a foreign body in the conjunctival sac or one embedded in the cornea are particles blown in by the wind, occupational or work-related injuries, and metallic foreign bodies that may fly into the eye, such as after a person hits a metal object with a hammer. It is important to evaluate the location of the foreign body and, in the case of corneal foreign bodies, the depth of penetration. Symptoms may be helpful; superficial foreign bodies in the cornea generally present with the complaint of a dust particle in the eye. Foreign bodies that have penetrated deeper into the corneal stroma produce a dull, aching pain perceived in or behind the eye.
On examination, it is important to look carefully at the inflammatory response of the eye. A purely localized conjunctival inflammation pattern is generally associated with superficial foreign bodies. Ciliary injection is a warning sign that a deep penetration may have taken place, and an oph-thalmologic consultation should be sought immediately. Examine the eye after the instillation of ophthalmic local anesthetic to avoid blepharospasm and evasive eye movements. Inspect the cornea with a penlight or ophthalmoscope in a darkened room. Use of the slit on the ophthalmoscope can help visualize irregularities in the corneal surface. Staining with fluorescein demonstrates abrasions and helps identify otherwise transparent foreign bodies.
The family physician may elect to remove a foreign body in the conjunctival sac by irrigation with a sterile solution or after eversion of the upper lid with a moistened cotton swab. In the case of superficial corneal foreign bodies, a physician may attempt to remove it with a moist sterile swab, but embedded foreign bodies should be referred to an ophthalmologist.
Corneal abrasions are often caused by foreign bodies underneath the upper lid or inadvertent injury from a finger or small object. Evert the lid and examine for conjunctival foreign bodies. To evert the lid, the patient is seated and asked to look downward. The upper lid is grasped by its central lashes and pulled downward and slightly outward. The examiner then depresses the upper lid with a cotton applicator proximal to the upper tarsus margin. Gentle pressure is maintained until the upper lid is flipped into the everted position. Frequently, the foreign body is observed and can be removed with a cotton applicator or forceps. Corneal abrasions generally can be treated with an antibiotic ointment. Small abrasions often do not require patching. Large corneal abrasions may require pressure patching or bandage contact lens.
If the conjunctival or corneal foreign body is not easily removed with a cotton applicator, the family physician should obtain ophthalmologic consultation. If the abrasion is not healed within 24 hours, an ophthalmic consultation should be obtained. Corneal abrasions should also be carefully inspected for other ocular injury. Any irregularity of the pupil in the presence of a corneal abrasion could signify an underlying occult penetrating injury. In such cases, the patient should be immediately directed to an ophthalmologist for further evaluation.
Patients suffering from contact lens overwear syndrome have worn their lenses longer than usual and typically awaken during the early-morning hours with severe pain and tearing. In response to prolonged wear, the cornea becomes swollen and develops epithelial defects. Patients need reassurance that the condition is usually not serious, even though the pain is severe. However, occasional contact lens-induced corneal abrasions, especially those associated with soft lenses, can rapidly progress to severe corneal infection. Patients should be seen the next day and referred if they have not improved. Contact lens wear may be resumed only after the corneal epithelium is well healed.
Metallic foreign bodies, if allowed to stay in the eye for a number of hours, frequently leave a "rust ring" that is clearly visible after removal of the foreign body. Rust rings irritate the cornea and result in long-lasting inflammatory changes in the eye. Follow-up should be daily, with staining of the cornea to demonstrate the expected rapid healing. If healing does not take place over 24 to 48 hours, suspect an infection in the corneal stroma and obtain consultation. Topical antibiotic ointments are used after removal of foreign bodies in an attempt to prevent this complication.
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