Eyeworld

97 EW RESIDENTS February 2015 nodules in the angle structures at 3–5 weeks." Dr. Weikert added, "This is why you must determine the severity of the ocular injury, par- ticularly if there is a penetrating in- jury or intraocular foreign material. Gonioscopy is very important. Make sure to retroilluminate through the pupil before dilation to assess for any transillumination defects. After dilating the patient, look in any areas of iris defects to assess for lenticular deformities. Even a small defect in the lens will give you an irregular red reflex." Dr. Hamill responded, "One of the good things about high-speed, low-mass projectiles is that they generally won't travel too far into the tissues." We asked how they would manage the superficial debris. Dr. Weikert replied, "The superficial material should come out easily using a 27- or 30-gauge needle at the slit lamp. Be cautious not to dig too deeply. It is very difficult to remove small particles from the stroma." Dr. Khandelwal said, "I have a low threshold for taking patients to the OR, especially if they are very uncomfortable and cannot sit still at the slit lamp. If you do this, it is important to precisely map out the corneal fragments at the slit lamp. In the OR, when the patient is hori- zontal, you tend to lose some depth perception, which can make remov- al more challenging." Dr. Weikert cautioned that removal of deeper particles might require corneal incisions that are significantly larger than the foreign bodies and the material may crum- ble when grasping is attempted. Magnets can assist in the removal of some metallic foreign bodies. We asked if the deeper frag- ments would eventually migrate an- teriorly, allowing for future removal. Dr. Hamill was confident that while the more superficial fragments would probably work themselves out, the more posterior fragments would probably remain stable. Dr. Khandelwal added, "Some blast injuries are associated with concomitant thermal injury, which may cause scarring and prevent anterior migration. However, a sand- blaster injury should not produce much heat at all. I would expect these to migrate superficially. You could consider using serial anterior segment OCT imaging to track the deeper fragments and see if they are moving." We asked what medication regimen to start the patient on. All panelists agreed upon topical antibiotics alone with no need for systemic coverage unless there was intraocular involvement. When the panel was asked about the role of topical steroids, Dr. Khandelwal said, "I would only use steroids as initial therapy if there was significant inflammation and no evidence of infection. I would consider their use after a few days if the likelihood of infection is very low and there is persistent inflammation." Case outcome After initiating broad-spectrum top- ical antibiotics, a 30-gauge needle was used to carefully remove the superficial particles at the slit lamp. More than 10 particles of various sizes were removed from the right eye, and more than 30 particles were removed from the left eye. Bandage soft contact lenses were placed and the patient was started on ofloxacin eye drops 4 times daily and lubricating ointment nightly. He returned 2 days later with mild relief of his pain. Two more particles were removed from the patient's left eye, and the bandage lenses were replaced in clinic. His best corrected distance visual acuities were 20/25 –2 OD and 20/100 OS, with manifest refractions over the bandage soft contact lenses of –1.00 + 0.50 x 170 and –0.50 + 0.50 x 180, respectively. The patient returned a day later for follow up with improvement in pain and a slight improvement in vision. There was no evidence of infection. He is currently scheduled for a 2-week follow-up appointment with plans to remove more foreign bodies as they surface over time. Take-home points This patient suffered a sandblasting injury resulting in numerous partial thickness foreign bodies to the corneas of both eyes. A thorough exam must be performed to rule out intraocular involvement. The foreign material should be identified to guide management and gauge the risk of ocular toxicity. Superficial debris should be removed at the slit lamp or in the operating room. The Putting quality, precision products into clinics and hospitals worldwide for over 30 years. www.tecfenmedical.com PRECISION OPHTHALMIC PRODUCTS Visit us at ASCRS San Diego Booth 755 patient should be started on topical antibiotics with daily follow up for the first 5–10 days to evaluate for infection. EW Contact information Weikert: mweikert@bcm.edu

• Cover