History of Present Illness
“ CC: I think something is in my left eye!” A backyard gate was closed with a chain and lock. The combination to the lock was lost, and so a 54-year-old man used a hammer and chisel in an attempt to break a link in the chain. After hitting the steel chisel with a hammer, he felt a sharp pain in the left eye (OS). His vision was still fairly good, and the sharp pain subsided, so he decided to wait until the next day before seeing a doctor. On awakening, he had mild discomfort OS and noticed sensitivity to light.
| OD | OS | |
|---|---|---|
| Visual acuity | 20/25 | 20/40 |
| Intraocular pressure (IOP) | 14 | 12 |
| Sclera/conjunctiva | Clear. No injection. | Focal conjunctival injection and a small (2 mm) laceration at 9:00 near the corneal limbus. |
| Cornea | WNL | Clear without laceration. Few fine nongranulomatous keratic precipitate (KP) inferiorly. |
| Anterior chamber (AC) | No flare or cell. | 1+ flare and 1+ cells |
| Iris | WNL | Pupil small but reactive to light and without an APD. |
| Lens | 1+ NS | 1+ NS |
| Vitreous cavity | Clear without vitreous cells | 1+ vitreous cells |
| Retina/optic nerve | WNL | IOFB, ≈2 mm in diameter, lying on retinal surface just below optic disc with adjacent hemorrhage (see Fig. 25.1 ) |
Questions to Ask
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Were you wearing glasses or protective lenses at the time of the injury?
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What was your vision like in both eyes (OU) before the accident?
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Have you had any previous eye surgery?
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Did you put any drops or ointment in your eye before visiting us?
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When was the last time you had something to eat and/or drink?
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Are you allergic to any antibiotics? Do you have other allergies?
He only wears glasses to read small print and was not wearing any protective lenses at the time of the accident. His visual acuity (VA) before the injury was 20/25 OU, and he had no history of previous eye surgery. No drops or ointment were placed in his OS before the visit. He had breakfast at 8:00 am , 8 hours ago. He is allergic to latex, but has no allergies to antibiotics.
Assessment
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Penetrating ocular injury, OS, with mild anterior uveitis
Differential Diagnosis
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Metallic intraocular foreign body (IOFB)
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Nonmetallic IOFB
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Traumatic anterior uveitis
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Idiopathic anterior uveitis
Working Diagnosis
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Metallic IOFB, OS, with traumatic anterior uveitis
Testing
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B-scan ultrasound ( Fig. 25.2 )
