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  Vol. 8 No. 5, September 1999 TABLE OF CONTENTS
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Synthetic Granuloma

Regarding treatment for synthetic fiber granuloma of the eye: Can a primary care physician manage this problem without an ophthalmology consult in patients presenting without visual problems?


It would be useful to generalize your question, and address the issue of when a primary care physician may safely manage conjunctival and corneal foreign bodies, and when referral to an ophthalmologist is indicated. There are 3 important considerations when making this decision: the history of the foreign body, the depth of penetration into the ocular tissue, and the age and cooperation level of the patient.

The history in most patients is clear, with a sudden onset of ocular pain or irritation associated with a particular activity. In children, however, the history may be unknown. In these cases, it is important to rule out the possibility that a foreign body may have penetrated the eye or orbit, because such injuries may result in sight-threatening complications. Signs of possible ocular penetration include decreased vision, subconjunctival hemorrhage, marked conjunctival swelling, clouding of the cornea, and absence of the red reflex. If there is a question of ocular penetration, then evaluation by an ophthalmologist is warranted.

If the history is known, the next consideration is the depth of the foreign body. Most conjunctival and corneal foreign bodies are superficial. These often can be removed in the primary care physician's office without the need for special equipment. Prior to attempting removal, topical anesthetic eyedrops should be placed in the eye to minimize discomfort. Simple measures are often effective in removing such foreign bodies. These include irrigation with a saline solution or gently swabbing the eye with a cotton-tipped applicator. In my experience, most primary care physicians are comfortable dealing with such problems. If penetration of deep tissue is suspected, or if a foreign body does not dislodge with the measures described above, then referral to an ophthalmologist is usually necessary.

The third important consideration is the age and cooperation level of the patient. Young infants (<1 year old) can usually be examined in the office, and superficial foreign bodies removed, while the infant is securely wrapped in blankets. Older children and adults are usually apprehensive, but are able to cooperate with gentle encouragement. Toddlers are the most difficult age group, and an adequate examination may be impossible in the office. In such children, and in those in whom a deeply penetrating foreign body is suspected, examination under anesthesia by an ophthalmologist may be necessary to assess an ocular foreign body accurately and safely remove it.

Gregg T. Lueder, MD
St Louis, Mo

Arch Fam Med. 1999;8:376-377.






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