(Gritty Eye) Have Significant Ocular Disease?

Home , Herpes simplex keratitis

J Accid Emerg Med: first published as 10.1136/emj.12.4.286 on 1 December 1995. Downloaded from Journal of to accident and emergency Accident and Do patients presenting Emergency departments with the sensation of a foreign body in Medicine 1995 12, 286-287 the eye (gritty eye) have significant ocular disease?

D.G.R. JAYAMANNE

Department of Ophthalmology, Newcastle General Hospital, Newcastle Upon Tyne, UK

SUMMARY for which steroid treatment may be beneficial include marginal keratitis, blepharitis, allergic con- A total of 1155 consecutive patients selected on junctivitis, episclentis, uveitis and viral conjunctivitis. symptomatology alone who presented to an oph- Disorders for which steroid treatment is contra- thalmic accident and emergency (A&E) department indicated include bacterial keratitis and herpes over a period of 3 months from a total patient popu- simplex keratitis. Non-ophthalmic trained medical lation of 3522 were assessed. The study showed practitioners show a high level of anxiety about that about 96% of the patients reporting a sensa- the management of ophthalmic disease.3 Inappro- tion of a foreign body in their eye had no serious priate use of topical ophthalmic steroid prepara- ocular disease. Most patients had a superficial tions can potentially result in significant visual mechanical injury or minor microbial infection. Ster- handicap from steroid-induced glaucoma or cata- oid drugs were prescribed to only 2.1 % of the racts.2 Accurate diagnosis of ocular disease is patients. Topical steroid treatment was contra- particularly important before treatment with topi- indicated in 0.35% of the patients. A low rate of cal steroids. This depends on examination using morbidity was noted, suggesting that these a slit lamp biomicroscope and other specialist patients could have been treated adequately in a ophthalmic techniques.3 general A&E department rather than an ophthalmic department. Key words: eyes, foreign bodies, steroid PATIENTS AND METHODS http://emj.bmj.com/ treatment During the 3 month study period, 3522 patients presented to the ophthalmic A&E department at the North Cleveland, UK for the first INTRODUCTION Riding Infirmary, time; the patients were either self-referred or referred a in their general (GPs). About 12 000 The sensation of foreign body the eye (gritty by practitioners on September 24, 2021 by guest. Protected copyright. eye) is a common ocular symptom.' Although most new patients are seen in the department every year. of these patients do not have significant ocular dis- Selection criteria for inclusion in this study were ease, it is important to carry out a careful clinical based on symptomatology alone. Patients in examination. Significant ocular disorders such as whom a sensation of a foreign body in the eye marginal keratitis and episcleritis may present with was identified to be the most significant symptom gritty, irritable eyes.2 The aim of this study was to were included in the study. A total of 1155 new identify the causes of the sensation of a foreign patients satisfied these criteria. The clinical Correspondence: body in the eye in a group of 1155 new patients records of these patients were reviewed retros- D.G.R. Jayamanne, presenting to an ophthalmic A&E department. pectively. All ocular examinations were performed Department of The study also reports the indications and by a junior ophthalmologist. These included visual Ophthalmology, incidence of topical steroid use in this group of acuity measurement, bio-microscopic exam- Newcastle General ination, eversion of the eyelids and fluorescein Hospital, Westgate patients. Road, Newcastle Medical practitioners are advised never to pre- staining. Direct and consensual pupil reactions upon Tyne NE4 6BE, scribe topical ophthalmic steroids without first seek- were also noted on all patients. Orbital radio- UK ing the opinion of an ophthalmologist.2 Disorders graphs were performed on all patients with a

© 1995 Blackwell Science Ltd. J Accid Emerg Med: first published as 10.1136/emj.12.4.286 on 1 December 1995. Downloaded from D.G.R. Jayamanne history of high velocity injury (e.g. hammering or treatment from GPs. Despite the limitations, drilling metal on metal). however, this study provides information on the incidence of acute disorders in the community. By far the largest percentage of patients with R ES U LTS the sensation of a foreign body in the eye had During the 3 months of the study about 35% of mechanical injuries to the eye such as foreign new patients presenting to the A&E department bodies, glancing blows and other superficial stated that the sensation of a foreign body in the trauma causing corneal abrasions. Microbial eye was the most significant ocular symptom that conjunctivitis and seasonal allergic conjunctivitis affected them at the time of presentation. A total were the most common non-traumatic disorders of 13% of the patients reported solely such a in this study. The incidence of herpes simplex sensation in the eye, with no other associated keratitis presenting as the sensation of a foreign symptoms. The sensation of a foreign body was body in the eye was low. Fluorescein staining associated with lacrimation in almost 50% of revealed all herpetic, marginal and traumatic patients. Three per cent of patients with a corneal ulceration of the cornea, and should therefore be foreign body required an orbital radiograph to carried out routinely in all patients with such a exclude an intra-ocular foreign body. sensation in the eye. By far the most common cause of the sensation Most ophthalmologists are concerned about the of a foreign body in this group of 1155 patients inappropriate use of steroid treatment by non- was a superficial non-penetrating corneal foreign ophthalmic medical practitioners and feel that body. About 75% of these patients had a clear steroid preparations should not be used without history of trauma. The results of this study are specialist advice.4 In this group of patients, which summarized in Table 1. included about 35% of all new patients attending the ophthalmic A&E department, only 2.1 % of DISCUSSION patients required a steroid preparation as a part of their treatment. The ocular disorders for which There are limitations to this type of study. Over the steroid treatment was essential included patients study period the prevalence data represent only with uveitis, marginal keratitis and episcleritis. In disease in patients who sought hospital treatment this study only four patients (0.35%) had disorders at the time and exclude all those patients receiving strongly contraindicating the use of topical steroid treatment, i.e. herpes simplex keratitis. A low rate of morbidity noted in most patients http://emj.bmj.com/ Table 1. Incidence of each cause of the sensation of provides strong evidence that ophthalmic foreign body in the eye as a percentage of the total emergency services can be provided adequately number of patients in the study (n = 1155) by general departments, but close liaison with the Diagnosis Incidence ophthalmology departments should be maintained so that rapid access is available for patients with Corneal foreign body 67.8 complicated ophthalmic disease. on September 24, 2021 by guest. Protected copyright. Corneal abrasion 13.6 Bacterial/viral conjunctivitis 9.1 None found 2.9 REFERENCES Allergic conjunctivitis 1.6 1. Thiry D. (1979) Ocular symptomatology in general Marginal keratitis 1.4 practice. Revue Medicale de Liege 34, 803-810. Tarsal cyst 0.8 2. Claoue C.M.P & Stevenson K.E. (1986) incidence of in- 0.8 Blepharitis appropriate treatment of herpes simplex keratitis with Dry eye syndrome 0.6 topical steroids. British MedicalJoumal 292, 1450-1451. Episcleritis 0.4 3. Wilson A. (1987) The red eye: a general practice Herpes simplex keratitis 0.3 Journal of the of General Trichiasis/entropion 0.3 survey. Royal College Anterior uveitis 0.2 Practitioners 37, 62-64. Contact lens keratitis 0.2 4. St Clair Roberts D. (1986) Steroids, the eye and general practitioner. British Medical Joumal 292, 1414-1415.