Ophthalmologic


Corneal Foreign Body Removal

Rapid Review

  • Background
    • Common corneal foreign bodies include metal, glass, plastic, wood, and sand. Must be removed in a timely manner to prevent infection and ocular necrosis
  • Indications
    • Foreign body in the cornea
  • Contraindications
    • Intraocular foreign body, hyphema, corneal laceration, multiple foreign bodies
  • Complications
    • Incomplete removal, conjunctivitis, epithelial injury, corneal perforation.

Pearls

  • Use a small needle for removal (30 or 25 gauge needle). You can also try to remove with cotton swab or irrigation to minimize corneal damage. 
  • After removal, repeat fluorescein exam and look for Seidel defect to ensure that you did not perforate the cornea.
Video Credit: Larry Stack


Globe Luxation Reduction

Rapid Review

  • Background
    • Occurs when the eyelids slip behind the midcoronal plane of the eye in a proptosed eyeball. Orbicularis oculi spasm maintains luxation. Early reduction is required to minimize visual impairment
  • Indications
    • Spontaneous or traumatic globe luxation
  • Contraindications
    • No absolute contraindications. Globe rupture is a relative contraindication. 
  • Complications
    • Failure to reduce, retained lashes.

Pearls

  • Topical anesthetic drops (tetracaine, proparacaine) can reduce pain and decrease belpharospasm, allowing the provider to reposition the globe more easily. 
  • When manually reducing, gentle pressure should be applied to the sclera. Avoid putting any pressure on the cornea. 
Video Credit: Kiki Nauli


Lateral Canthotomy

Rapid Review

  • Background
    • Lateral canthotomy is the surgical exposure of the lateral canthal tendon, +/- incision of the inferior branch of the tendon (cantholysis), to relieve intraorbital pressure.
  • Indications
    • Orbital compartment syndrome (w/ acute loss of vision acuity, proptosis, or IOP > 40)
  • Contraindications
    • Suspected globe rupture
  • Complications
    • Globe injury, lacrimal gland/artery injury, incomplete cantholysis, bleeding, infection

Pearls

  • All equipment being used during the procedure (needle, hemostats, scalpel) should be directed away from the eye
  • If the IOP is still > 40 mmHg after cutting the inferior canthal tendon, you may need to proceed with incision of the superior canthoal tendon.
Video Credit: EM:RAP


Slit Lamp Exam

Rapid Review

  • Background
    • Examination of the eye under magnification to identify pathology within the anterior aspect of the eye and help provide treatment for ocular foreign body removals.
  • Indications
    • Evaluation of red eye complaints
    • Suspected corneal foreign body 
  • Contraindications
    • None
  • Complications
    • None

Pearls

  • To maximize comfort, avoid focusing the beam directly on the patient’s eye when you start.
  • If looking at the entire eye at once, use a broad beam. Use the narrow beam when evaluating the anterior chamber specifically. This also helps with patient comfort.
Video Credit: ALiEM


Tonometry

Rapid Review

  • Background
    •  Diagnostic test that measures intraocular pressure.. Early detection of abnormal intraocular pressure can prevent irreversible vision loss
  • Indications
    • Suspected glaucoma, ocular trauma w/o globe rupture, before/after ophthalmic surgical procedures.
  • Contraindications
    • Infection, unhealed corneal abrasions/ulcers, ruptured globe
  • Complications
    • Infection, corneal abrasion, aggravation of ruptured globe.

Pearls

  • Tonometry can be very uncomfortable for the patient. Consider applying topical anesthetic (tetracaine, proparacaine, etc.) to the affected eye ahead of time.
  • Do not hold the eye during the procedure; this may give a falsely high reading. Try to avoid pulling up/down on the eyelids as well.
Video Credit: ALiEM

Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021