LEFT CORNEAL FOREIGN BODY IN A WELDER: AN OCCUPATIONAL HEALTH HAZARD

Presenting Complaint:

 Excessive watery discharge with pain and foreign body sensation in the left eye of two days’

duration

History of Presenting Complaint:

JC was welding an iron-rod at the mechanic workshop of his workplace when a metallic foreign body hit

him on the left eye. This was immediately followed by excessive watery discharge from the affected

eye, in addition to severe pain and foreign body sensation. The discomfort was exacerbated by eye

blinking and rubbing of the eye. One hour later, he developed left-sided frontal headache as well as

photophobia and redness of the left eye. He also noticed a reduction in his vision in the affected eye

and this could not allow him to do his job satisfactorily. This frightened him and he thought the injury

might have caused great damage to the affected eye in view of its delicate nature. However, further

enquiries revealed that he was not wearing protective goggles at the time of the accident. Prior to

presentation, he sought for treatment at a private clinic where chloramphenicol eye drop and penicillin

ointment were given to him for application to the affected eye. The next day, his vision and pain got

worse notwithstanding the application of the aforementioned medications. In view of his deteriorating

vision and increasing pain, he decided to come to the Federal Medical Centre, Owerri, for

ophthalmological work up.

Review of Systems:

There was no history of fever, associated itching or bleeding from the left eye.

Past Medical History: There were no known major medical problems. He had an appendectomy at the

age of 16 years. There was no history of hypertension, diabetes mellitus or sickle cell disease and no

known history of medication allergies.

Family and Social History: He was married to one wife, a civil servant in the employment of the State

Government and had two children, all of whom were hale and hearty. He lived in a three bedroom self-

contained apartment with his family. He neither took tobacco in any form nor drank alcohol. He did not
use illicit drugs. Furthermore, he gave information that his company would defray the cost his medical

expenses as part of the employee compensation benefits.

Physical Examination:

General Examination: He was obviously in painful distress, otherwise he looked healthy; afebrile

(temperature of 36.70C), not pale, had copious watery discharge from the left eye, which he constantly

wiped up with a handkerchief.

Right Eye Examination: Visual acuity was 6/6. The lids were normal. Tonometry revealed intraocular

pressure of 12 mmHg. The conjunctiva, cornea, pupil, anterior chamber, lens and fundus were

essentially normal.

Left Eye Examination: The left eyelid was slightly swollen. Visual acuity on the left eye was 6/9.

Tonometry done after instillation of 1 drop of 2% tetracaine (an anaesthetic) into the left eye revealed

an intraocular pressure of 12 mmHg. The conjunctiva was injected. There was a foreign body noticed at

the inferiomedial aspect of the limbus (corneoscleral junction) at about the 4 o’clock position. The pupil

reacted normally to light (both directly and consensually) and was of normal size and shape. The

anterior chamber, lens and fundus were essentially normal. Fluorescein dye test also revealed a

metallic foreign body on the cornea at the same position, making it more apparent, with the surface

stained by the dye and appeared green under the blue light.

Cardiovascular System Examination: The pulse rate was 84 beats per minute, regular and of full

volume. Blood pressure was 120/80mmHg. The JVP was not raised and the first and second heart

sounds were normal.

Respiratory System Examination: The respiratory rate was 18 cycles per minute. Percussion notes

were resonant and vesicular breath sounds were heard in all lung zones, no added sounds.

Abdominal Examination: His abdomen was full and moved with respiration. There were no areas of

tenderness. The spleen and liver were not palpably enlarged and the kidneys were not ballotable.

Bowel sounds were present and normoactive.

Central Nervous System Examination: He was conscious and alert and well oriented in time, place

and person. The muscle tone, power and reflexes were normal. There were no focal neurological signs.
Diagnosis: A diagnosis of left corneal foreign body was made.

Management:

The diagnosis and management plan were explained to the patient; his anxieties were allayed. The

need for immediate intervention was explained to him and he was assured that the foreign body would

be removed through a minor procedure at the treatment room and he gave a written consent.

Procedure for Removal of Foreign Body:

The patient was taken to the treatment room for removal of the foreign body. He was put in the supine

position and two drops of 2% tetracaine were instilled on the cornea of the left eye to anaesthesize it.

Thorough irrigation with sterile normal saline was done. Topical aneasthesia was reapplied and allowed

to stay for two minutes after which an eye spud was used to remove the foreign body. It was a piece of

metallic particle. A repeat fluorescein dye test and irrigation revealed a superficial corneal abrasion.

The eye was irrigated again with normal saline. Gentamycin and 2% homatropine eye drops followed

by chloramphenicol eye ointment were applied to the left eye. The left eye was padded and patient was

observed for six-hours. The procedure was well tolerated. He was given paracetamol tablets 1000 mg

thrice daily for three days. The removed foreign body was shown to JC.

Review after six hours: The pain in the left eye had reduced and the padding was removed.

Examination of the right eye showed minimal watery discharge and a slightly hyperemic conjunctiva.

The pupil was dilated from the effect of the homatropine applied. Fundoscopy done was normal. He

was sent home to continue six hourly gentamycin and 12 hourly 2% homatropine eye drops, with

chloramphenicol eye ointment at night for five days. He was scheduled for review the next day.

First day post-procedure: He was much relieved after he used all his prescribed drugs. The

conjunctival injection had improved and the left cornea was clear on examination. Watery discharges

had subsided. He was counselled on preventive eye care. He was educated on ocular injury and its

complications with particular emphasis on the importance of the use of protective eye goggles when at

work. He was given a two-week appointment to the ophthalmology clinic.

Two weeks appointment: JC came to the clinic with no complaints. Visual acuity was 6/6 in both eyes.

The lids were normal. Tonometry revealed intraocular pressure of 12 mmHg in both eyes. The
conjunctiva, cornea, pupil, anterior chamber, lens and fundus were essentially normal. He had resumed

work and claimed he had started using protective eye glasses during welding operations. The benefits

of preventing eye injuries (in view of the delicate nature of the organ) and the use of appropriate

personal protective equipment while at work were reiterated and he was discharged from the clinic.

Discussion:

Eye injuries account for a substantial proportion of all work related injuries worldwide and the

pattern seen in various parts of the world essentially depends on local prevailing conditions. 1 It is a

common cause of ophthalmic consultation in both the primary care physician’s office and the

emergency departments and remains a common cause of preventable unilateral blindness in the

industrialized and developing world.1-4 Ocular injury may be caused by a blunt injury, penetrating or

foreign body in the eye.4-6 In JC, the cause of his eye injury was a metallic foreign body, which entered

the cornea and became lodged within the stroma without perforating the eye.

The cornea is highly susceptible to superficial injury and a frequent target for foreign bodies which

are wind-swept or directed into the eyes in occupations that utilize grinding machines 7 as was the case

in JC. Corneal abrasive injury results because of the delicate nature of its epithelium and abrasive

injury causes immediate and often severe pain, redness of the conjunctiva and intense lacrimation7 as

was JC. This is because the cornea is richly supplied by sensory nerve endings via the first division of

the trigeminal nerve.7

Corneal foreign body is a foreign material on or in the cornea, usually metal, glass, or organic

material. The portal of entry is through the cornea, limbus and sclera in 65%, 20% and 15 % of the

cases respectively with the left eye being more commonly affected than the right 6-8 as was the case in

JC. Generally, males are more frequently involved than females with a ratio of 4:1 and this has been

attributed to greater activity in males than females.1,4-6,8 In this part of the world, a number of

occupations are male oriented and in some cases dominated. 4 JC worked as a welder at the

mechanical workshop of the Imo State owned palm oil mill, which specialized in the production of palm

oil and kernels. He engaged in welding operations at the factory without the use of protective eye

goggles and this resulted in a work-related foreign body injury to left eye. This was diagnosed easily
after a clinical examination hence there was no need for radiological confirmation. 9 The foreign body

was removed with a sterile foreign body spud after topical anesthesia. Antibiotic was applied to the eye

before and after the removal. Other methods of removal include irrigation, use of sterile hypodermic

needle (with a slit lamp microscope) and cotton-tipped swab soaked in saline.6,7,9 The abrasion usually

heals rapidly within 24-48 hours unless a secondary infection causes a corneal ulcer. Antibiotic drops

and ointment applied to JC’s left eye facilitated the healing of his corneal abrasion, thus, preventing

superimposed bacterial infection and its attendant complications.6

Most cases of ocular injury can be managed in the physician’s office. JC’s left eye was padded to

prevent rubbing of the eyelids over the injured cornea, thus, reducing pain and enhancing healing. 7

However, recent randomized control trials have shown that treating simple corneal abrasion with a

patch does not improve healing rates on the first day post-injury and does not reduce pain; and use of

patches prevent binocular vision, reduce the visual field, could potentially predispose the eye to

anaerobic infections, and may in fact worsen discomfort and slow recovery.10,11 He recovered fully

without any residual visual loss. For medico-legal reasons and to assess improvement after treatment,

JC’s visual acuity was determined at presentation, during and after treatment. The visual acuity in JC’s

left eye improved from 6/9 to 6/6 using the Snellen’s chart before and after the procedure and during

follow up clinic visits. It is important to find out the circumstances surrounding the injury as this will

assist in proper counselling of the patient. JC was advised to use protective goggles and other personal

protective equipment while undertaking welding operations.3-6,8 Early presentation to hospital by

patients with ocular trauma, in addition to prompt and proper intervention remain critical to prevention of

complications like cataract, hypopyon, endohphthalmits and vitreous haemorrhage.2,6,7,9 Ocular injuries

are of considerable socio-economic importance. JC was absent from work for many days and following

successful treatment, he was issued a medical report to his employers, who were advised to enforce

and ensure strict compliance to safety standards by employees at their various places of work. He was

apprehensive of the injury because it is a dominant sensory organ and because eye care services were

not readily accessible in his vicinity. However, maldistribution of eye care workforce is unevenly

distributed between the rural and urban areas of Nigeria as was observed in a recent study in Enugu. 12
Most ophthalmological facilities are concentrated in the urban areas. This creates a major barrier to

uptake of eye care services especially in rural areas.

Treatment of some emergency eye conditions is within the confines of the competences of the

family physician. However, after the initial measures, a decision may be taken, whether to treat or to

refer the patient to an ophthalmologist since a minor injury to the eye, as depicted in JC’s case, could

become very serious if not properly managed. JC’s left corneal foreign body was removed by the author

under the supervision of the unit consultant ophthalmologist at the centre.

This case brings to the fore the need for adequate and appropriate use of personal protective

equipment to prevent injury at work and associated lost time injury and disabilities. The family physician

has a critical role to play in patients’ counselling and education concerning accident prevention and

safety practices. It is imperative that workers performing welding tasks or working nearby welders

should be trained to recognize potential hazards and the effective use of proper personal protective

safety equipment to prevent ocular injury, which by so doing, would reduce the incidence and

prevalence of eye casualties at the workplace. It is recommended that legislation requiring the use of

protective devices in high-risk industries should be vigorously enforced to improve the eye health of

Nigerian industrial workers.

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