OPHTHALMOLOGY

Case 2
- BAKSHI PUNEET
- ARAMBAM MREENALINI
General Data
• Name- X
• Age- 54
• Sex- Male This Photo by Unknown Author is licensed under CC BY-SA

• Occupation- Works in metal workshop

Chief complaint
• Redness, slight lacrimation and gritty sensation of LEFT eye
 History of present illness

3 DAYS PTC After working on metal bars with handheld metal-grinder

CONSULTATION redness, slight lacrimation, and gritty sensation of the left eye
Physical examination findings
LEFT EYE
• reddish
• Reddish-brown round object adherent to the temporal area on slit
lamp examination.
• (-)discharge
SALIENT FEATURES
• Redness
• Occupation: metal workshop
• Slight lacrimation
• Gritty sensation
• Photosensitivity
• Works on metal bars with handheld metal grinder
• Reddish brown round object adherent to temporal area of left cornea
Initial impression
• CORNEAL FOREIGN BODIES
Differential diagnosis
• Uveitis/iritis
• Corneal abrasion
• Corneal Ulcer
Uveitis
• Uveitis refers to inflammation of any part or whole of the uveal tract. Uveal
tract includes iris, ciliary body and choroid.
• The term uveitis strictly means inflammation of the uveal tissue only. However,
clinically there is always some associated inflammation of the adjacent
structures such as retina, vitreous, sclera and cornea. Due to close relationship
of the anatomically distinct parts of the uveal tract, the inflammatory process
usually tends to involve the uvea as a whole. However, the uveitis is classified
according to the part of uvea which is clinically more affected.
• Inflammation of the uvea fundamentally has the same characteristics as any
other tissue of the body, i.e. a vascular and a cellular response. However, due to
extreme vascularity and looseness of the uveal tissue, the inflammatory
responses are exaggerated and thus produces special effects.
Uveitis
RULE IN RULE OUT

Photophobia (-) blurring of vision

Eye Redness (-)floaters

Sudden onset( acute) (-) decrease vision

Lacrimation (-)eye pain

 This Photo by Unknown Author is licensed under
CC BY-SA

Corneal abrasion
• Corneal abrasion refers to a condition where the surface of the cornea, the clear front part of the eye,
becomes scratched or injured. It is a common eye injury that can occur due to various reasons, such as:
1. Foreign objects: Dust, dirt, metal particles, wood chips, or other foreign bodies that come into contact
with the eye can cause a corneal abrasion.
2. Eye trauma: Direct injury to the eye, such as a poke, scratch, or impact, can result in a corneal
abrasion.
3. Improper use of contact lenses: Incorrect insertion or removal of contact lenses, using lenses with
defects or dirt particles, or wearing them for an extended period can lead to corneal abrasions.
4. Rubbing the eyes: Vigorous rubbing of the eyes, especially when there is a foreign object present, can
cause corneal abrasions.
5. Chemical exposure: Contact with certain chemicals, such as acids or alkalis, can damage the cornea
and result in an abrasion.
• Symptoms of a corneal abrasion may include: Eye pain or discomfort, Redness and irritation,
Excessive tearing, Sensitivity to light (photophobia), Blurred or decreased vision, Foreign body
sensation or the feeling of having something in the eye, Eye discharge
Corneal abrasion
RULE IN RULE OUT

Redness of eye (-)pain

Gritty feeling in eye (-)blurry vision

Sensitivity to eye (photophobia) (-)tearing

Presence of foreign body

Corneal ulcer
• A corneal ulcer is a defect in the surface
epithelium of the cornea that involves the
underlying stroma.
• It is common in contact lens wearers and
presents as eye pain, blurry vision, and
photophobia. This Photo by Unknown Author is licensed under CC BY-NC
Corneal ulcer
RULE IN RULE OUT

Redness of eye (-)Blurred vision

Photophobia (-)Watering from eye

Foreign body sensation (-)Blepharospasm

FINAL DIAGNOSIS: Corneal foreign
bodies
• It occurs due to impaction of foreign bodies in
cornea
• In cornea, it is usually embedded in the epithelium
or superficial stroma and rarely into the deep
stroma.
• A foreign body produces immediate- Discomfort,
profuse watering and redness in eye, Pain and
photophobia
• Defective vision occurs when it is lodged in centre
of cornea
Diagnostic test
• All patients suspected of having a corneal foreign body should also undergo a slit lamp
examination. Care should be taken to inspect the entire eye as well as flipping the upper lid,
as foreign bodies can hide under the tarsal plate and introduce micro-trauma with every blink
of the eye. This should first be without fluorescein dye, inspecting the lids and lashes, the
conjunctiva, the sclera, looking for injection, chemosis, anterior chamber depth, cell and flare
within the anterior chamber, and as well as any readily apparent foreign bodies.
• Upon adding the fluorescein, a general inspection should be performed again, looking for any
corneal abrasions or lacerations. The dye will also allow you to perform the Seidel test,
which, when positive, indicates globe perforation. In a positive test, you would expect to see
a flow of aqueous humour as a waterfall appearance at the site of trauma. Another more
subtle finding which indicates a positive Seidel test is a lighter color dye in one location due
to the dilution of the dye by the aqueous humor. This is a finding in very small globe
perforations.
• Limited bedside ultrasound is also useful to assess for vitreous hemorrhage or retinal
detachment.
• However, extreme caution is recommended again, as any pressure to the globe may cause
Treatment

• Eye is anaesthetize with topical instillation of 2 to 4% xylocaine

• The patient is made to lie supine on an examination table.
• Lids are separated with universal eye speculum, the patient is asked to look straight upward and
light is focused on the cornea.
• First of all, an attempt is made to remove the foreign body with the help of a wet cotton swap
stick.
• If it fails then foreign body spud or hypodermic needle is used.
• Extra care is taken while removing a deep corneal foreign body, as it may enter the anterior
chamber during maneuvering.
• If such a foreign body happens to be magnetic, it is removed with a hand-held magnet but MRI
is contraindicated
• After removal of foreign body, patching with antibiotic eye ointment is applied for 24 to 48 hours
• Antibiotic eye drops are instilled 3-4 times a day for about a week.
Complication
• Acute bacterial conjunctivitis may occur from infected foreign bodies
or due to rubbing wiLh infected hands.
• Corneal ulceration may occur as a complication of corneal foreign
body.
• Pigmentation and/ or opacity may be left behind by an iron or emery
particles embedded in the cornea.
Prevention

• Industrial and agricultural workers should be advised to use special

protective glasses.
• Cyclists and scooterists should be advised to use protective plain
glasses or tinted goggles.
• Special guards should be put on grinding machines and use of tools
with overhanging margins should be banned.
• Eye health care education should be imparted, especially to the
industrial and agricultural workers.
REFERENCES:
• AK KHURANA
• National Library of Medicine
This Photo by Unknown Author is licensed under CC BY