Introduction:
Accidents occur when people are careless, but the clinician should be aware that even with utmost precautions, such as consistent use of goggles, foreign matter may find its way into the eye. It is therefore important to emphasize protective eyewear; however, if the history reveals numerous incidents despite use of protective eyewear, the clinician should either question the accuracy of the patients' statements or examine the goggles if possible.

When an injured patient is in the chair, remember that you may not have as much time since the patient is in pain in many cases. Here, the clinician must be efficient and ask the proper and the important problem focused questions and get on with the objective examination.

1.) History:
When a patient comes in with a red eye it is of the utmost importance that a very thorough and complete history be taken. It should contain when the condition started or when it happened. What were the circumstances/conditions surrounding the incident.

• a) Was the patient hit in the eye with something and if so with what? Wood, metal, glass, pizza, etc.; or were they hammering on something if so, on what, with what?
• b) When did the condition start? Was it a week ago, this morning, two days ago, just when did the patient first notice the condition.
• c) Has the patient taken any thing for pain, if so what and has it helped? Has he/she put anything in his/her eye, if so what? In other words, has there been an attempt to treat the condition? If there has been a treatment, what was its nature? With what? Was a vasoconstrictor involved, which now makes the eye less red.
• d) You need to know as much about the cause as you can elicit from the patient. This should start you thinking about what you are looking for, how severe the condition may be, and what kind of treatment you may have to initiate. If the injury has resulted because the patient was hammering metal on metal, for example, you have to think about the possibility of a penetrating foreign body due to the higher speed of the projectile as opposed to something "falling" in the eye.
• e) If you determine the patient does have a penetrating injury only use a fox shield or the lower part of a paper cup, with no wax coating, and apply just enough tape to hold it in place. DO NOT PRESSURE PATCH! Patient then must be referred to an ophthalmologist or emergency room.

2.) Visual Acuities:
The patient may be in a great deal of pain and not able to open his/her eyes, but you must obtain some degree of visual acuities. The full length of your two arms outstretched is approximately equal to your height and at this distance your fingers are approximately equal to 20/200 which should be recorded as finger counting at that test distance . Therefore, you can get some idea as to a patient's vision even if it is crude because time is important. You should of course try to get snellen acuities if you can even if you first have to place a topical anesthetic in the eye, one drop of 0.5% Proparacaine HCl should be adequate. Taking acuity is important both from a legal stand point and also as a measure of your success in treating the condition (pre/post comparison).

3.) You must do a very complete slit lamp examination of the patients eye and at this point if you have not had to use a topical anesthetic you most likely will, but hold off using the anesthetic as long as possible.

a ) Are the pupils equal in size and do they react equally to light? Small pupil might indicate an anterior uveitis.

b ) Is there a consensual pain reflex present indicating a smoldering anterior uveitis or an embedded foreign body.

c ) Is there conjunctival injection or is the injection more limbal in location? What degree of redness are you seeing: slightly red or very bright red? Conjunctival blanching is also an important sign. It might indicate chemical insult to the eye, which has to be ruled out.

d ) Is the anterior chamber clear or are there cells and/or flare present and what grade of cells or flare are you seeing?

e ) Does the iris look normal or does it have a muddy appearance again indicating an anterior uveitis?

f ) What does the cornea look like without stain (sodium fluorescein). NOTE: You should never use Fluress® as the initial anesthetic of choice because the sodium fluorescein will enter the anterior chamber before you have had a chance to evaluate it for cells and flare.

g ) You should now evaluate the cornea and conjunctiva with sodium fluorescein taking note of any staining and its extent and depth. At this point also look very carefully for any percolating fluid from the eye which will look like a dark drainage against the fluorescein green color of the tear film. This is called the percolation test for a penetrating injury to the eye; and if you notice the waterfall effect described (a.k.a. Seidel's sign), follow the instructions above under HISTORY part (e) and refer the patient.

h ) Make sure to evert the upper tarsal plate and examine the lower lid checking for foreign bodies. If it has been a windy day the patient may have a foreign body located just under the edge of the upper lid which is the most common location (subtarsal fold). You should also pay attention to a very typical foreign body track staining pattern. The foreign bodies located on the palpebral conjunctive can usually be removed with a Q-Tip that has been moistened with saline. If there are any foreign bodies or you suspect their presence due to patient complain, remember that you MUST double evert the lid.

NOTE: Keep in mind that the patient has had to be anesthetized. Remember to educate the patient to tell you if the foreign body sensation returns after your examination (when anesthesia has worn off). This may mean there is more matter left in the eyes.

To double evert, use a paper clip that is bent open to an angle of approximately 90 degrees. Use the paper clip to evert the lid just as you would using a cotton swab, but now because of the angle of the clip while it is partially "sandwiched" between the everted lid and the upper lid skin, you will be able to pull up and back on the exposed end of the clip and look underneath the already everted lid. This technique will be demonstrated to you in class. You may also use a cotton swab for this purpose.

i ) f you find a foreign body lodged in the cornea or conjunctiva your first method to remove it should be to try flushing it out, preferably with a pressurized saline solution. You should first place one or two drops of .5% Proparacaine HCl in the eye before trying to force or blast the foreign body out. Have the patient look in a direction away from you so they will not see the spray of saline coming.

j ) It is extremely important that you document the type and location of foreign body you have removed with a drawing, what was used to remove the foreign body, any post removal procedures, i.e. (removal of rust ring), any and all medications that have been placed in the eye and the amount, the time of day the procedure was performed, and the date and time the patient is to return for a follow up visit. In most cases this will be in less than 24 hours. If the patient fails to show up for his/her appointment, call and document that you called along with the time, date and what the patient said, or whether you were able/unable to leave a message.

k ) Once the foreign body has been removed, if there is an anterior uveitis, you should then instill one or two drops of 5% Homatropine into the eye and always wait to make sure the eye starts to dilate before patching the patient, if indicated (see below). There are very good reasons for using Homatropine over other agents.

First, it helps restore the impermeability to the iris vessels which prevents the release of cells and proteins (flare) into the anterior chamber.

Second, it prevents a posterior synechiae from forming thus preventing the possibility of secondary glaucoma.

Third, it causes cycloplegia thus knocking out the ciliary muscle and preventing ciliary spasms and pain. It makes the patient much more comfortable.

NOTE: In the cases of frank iritis, where there is already some synechiae starting to form, cyclopentolate may be a better agent since it will allow some "rocking" of the iris in response to light and thereby break the adhesions before they become too strong. Important: Don't forget to tell the patient they will not be able to see at near is the cycloplegic medication NOT the red eye.

There are certain conditions that you do not want to patch.

First, patients with a corneal ulcer. Even though you may be using a wide spectrum antibiotic under the patch the cornea has an open infection There are certain microorganisms that antibiotics might not be able to combat. The patch makes for a nice warm dark environment for them in which to grow.
Second, patients who have developed abrasions secondary to soft contact lens over wear. Since, it was the contact lens covering the cornea that caused the problem in the first place it is not prudent to keep the cornea covered again using a patch. Studies have shown that in these cases the corneas healed much faster when not patched. This means the patient should be dilated and medicated, sometimes around the clock depending on the severity of the contact lens induced keratitis. Pressure patching prevents fully medicating the patient and hence is strongly contraindicated. Additionally, the patch will further deprive the cornea from oxygen, which is the main problem to begin with (see below);
Third, chemical burns are also contraindications for patching. The chemical agent may not have been thoroughly lavaged from the eye. Patching will allow extended exposure to the agent under closed lids and is strongly contraindicated.

Important NOTE: Management of corneal abrasion secondary to Soft Lens Associated Corneal Hypoxia (SLACH) may include aggressive antibiotic therapy. If there is no ulcer Tobrex® solution or gentamycin might be indicated during waking hours and an ointment (Polysporin®) for night time protection. Ciloxan and Ocuflox are new agents which have quickly become the standard of care for management of SLACH/ulcer secondary to soft lens wear. In case of an ulcer, particularly if the floor of the ulcer stains indicating an infected lesion, the new standard of care (the old being fortified tobramycin which is still widely used) is fluroquinolones (Ciloxan®). The dosage for an infected ulcer is: One to two drops every 15-30 minutes for the first two hours, then reduce to one drop every two hours AROUND THE CLOCK for the first 24 hours. Then reduce to only during waking hours along with tobramycin or Polysporin® ointment for night time coverage.
ITEM: In many soft lens-related corneal complications, Tobradex must be given serious consideration. This combination agent (tobramycin/dexamethasone) is an antibiotic/steroid preparation, which is very helpful in preventing secondary infections as well as reducing the possibility of infiltrative scarring of the cornea.

If you choose to pressure patch, keeping in mind all the contraindications, it is very important that the pressure patch is applied correctly. You want just enough pressure so as to prevent blinking (the patient should not be able to open the eye under the patch). You want to keep the lid from moving over that cornea and causing discomfort to the patient. If the patch comes loose during the night, it is possible that it will need to be replaced. If the patient is not capable of correctly applying the patch, it is up to the clinician to provide after hour service and re-apply the patch. There is such a thing as too much pressure being applied with a patch. You do not want the patch so tight that it causes the intraocular pressures to rise and cause discomfort to the patient.

Alternative to traditional patching is to use a bandage contact lens. This has the benefit of allowing oxygen to get to the cornea and also it is better tolerated by some patients. Also, the patient is now able to use antibiotic drops during the day over the contact lens for better antibacterial protection. However, in severe abrasions you still must consider pressure patching as you will practice in lab. Therefore, do not think of the contact lens method as a panacea. There are varying opinions on when and how it should be used. Sometimes it is used later in the course of treatment after some abrasion healing has occurred, to reduce corneal edema induced by pressure patching. Most recent clinical trials have, on occasion, RECOMMENDED use of the bandage lens along with pressure patch for added protection.
NOTE: The topic of "to patch or not to patch" is a constantly ongoing battle. Pressure patching continues to fall out of favor. In fact, some advocate NO patch at all even when the cause of abrasion is not among the categories listed above. It is felt that oxygen is the most important need of the cornea and any type of patch will compromise cornea's ability to receive oxygen. The size of the abrasion is also a factor. Pressure patching is now reserved for deep, large abrasions which border on lacerations of the cornea.

Since the patient will be in a great deal of discomfort, particularly early in the course of your treatment, recommend use of over the counter analgesics such as aspirin and/or acetaminophen. These two have a synergistic action, i.e., sum of the parts is GREATER than just an additive effect-- (2+2=8). Remember to ask about aspirin allergy. There will be cross sensitivity to other analgesics. Aspirin is contraindicated in the case of blunt traumas where there is a chance of internal bleeding. Acetaminophen (Tylenol) should not be taken in conjunction with alcohol due to high potential for liver toxicity.

The new analgesic agent, diclofenac, which is an non-steroidal anti-inflammatory drug (NSAID) used in oral form (Cataflam® or Voltaren®), or in some cases, in topical (Voltaren®) form should be used. Diclofenac is a very potent analgesic agent, however it does upset the stomach more than aspirin and it has cross sensitivity reaction with aspirin.

As of Fall of 1999, optometrists are allowed to prescribe a new oral analgesic medication named ULTRAM®, which is not an NSAID. It is classified as an OPIOID and therefore can be prescribed for cases of blunt trauma as it does NOT promote bleeding.

Ultram® is subject to warning regarding sleepiness. It may cause drowsiness and can only prescribed for a period of five days.

Foreign Body/Rust Ring Removal

Introduction:
We have added a new practice lab for you in this class. The eyes are made out of cooking gel, double strength, which may better simulate human eye than bovine or pig eyes. You will use a variety of instruments to remove the foreign bodies. We will supervise your technique.

Materials:
Loop: plastic and easier for younger patients. However, too large and not suitable for small foreign bodies.
Jeweler's Forceps: Adequate for foreign bodies embedded in the lid and some conjunctival matter. Not used on the cornea.
Lid retractor: Used in case of apprehensive patients.
Spatula: Used to “scoop” out the matter from cornea or conjunctiva. Its use is again limited due to its large size.
25 Gauge needle: Possibly the most useful tool to remove foreign bodies from the cornea if lavage has failed to do so. However, it easily penetrates Bowman's. The clinician must be extremely cautious with its use.
Algerbrush: Battery operated burr which is very useful for removal of rust and stain rings from the cornea. It must be used tangentially to the cornea, never at right angles. The burr tip rotates at high speeds, but it cannot penetrate the Bowman's if used properly. The rotation automatically stops when the tips comes in contact with any resistance. Invaluable for any optometric office.
Magnet: Useful for removing LOOSE metallic particles from the eye.

Techniques:
The first thing to remember when using any of the above instruments, is approach the eye tangentially. Have the patient look AWAY from the side of the approach. It is extremely important to ascertain the patient is immobile in the slit lamp and that he/she refrain from talking as that will cause the head to move. Do not forget anesthesia. Further illustration of the technique will be done during the lab.

NOTE: The clinician must realize that the removal of the foreign body is not the main issue. It is the rust ring removal which poses the problem in many cases. There are two important considerations that need to be addressed:

1.) The iatrogenic (doctor/procedure-caused) abrasion during the removal of the foreign body and mainly the rust ring is in many cases the main cause of the anterior uveitis, as well as necessitating the patch. Especially during rust ring removal with the Algerbrush, it is not only the foreign matter that is being removed, it is also the stained corneal epithelium that the brush takes off. The clinician must inform the patient about the course of the treatment and the fact that additional discomfort is likely given the procedure performed on a highly sensitive tissue.

It is best, however, to wait and not remove the rust ring until a few days have elapsed. This allows the wing cells to "fill in" the spot, thereby pushing the foreign matter/stained cells complex anteriorly. When this happens, removal of the complex becomes a relatively easy matter. Pursuing removal too early may cause unnecessarily large abrasion for extraction of relatively small amounts of foreign matter.

2: When the cornea has suffered any abrasion, whether iatrogenic or incident-induced, it is important to first warn and then guard the patient against the possibility of recurrent erosion.

Recurrent erosion is a term applied to sloughing off of the epithelial cells after an injury. This is the result of sub-clinical edema and/or damaged epithelial basement membrane. It typically occurs while the eye is closed. The patient generally experiences mild to severe discomfort in the middle of the night or upon awakening in the morning. This is obviously because of relative hypoxia which takes place when the eyes are closed.

To reduce the chance of recurrent erosion particularly following larger and deeper abrasions, hypertonic therapy is indicated.

Muro-128® or AK-NaCl® are concentrated saline ophthalmic preparations (2 and 5% solution; 5% ointment), which draw the edema out of the sub-epithelial area causing better adhesion of the cells to their basement membrane. It is best to wait till corneal healing has occurred so that the discomfort upon instillation is minimized. The patient then is placed on the hypertonic (drops and/or ointment) for 1-4 weeks depending on the severity of the original abrasion.