Attack of the sand brier

CASE REPORT foreign body, cornea

Attack of the Sand Brier

Corneal foreign bodies represent one of the more common sources of eye- related trauma presenting to emergency and primary care physicians. Pre- sented is the case of a man in whom the diagnosis was overlooked because a magnifying optical device was not used. [Miller KB: At tack of the sand brier. Ann Emerg Med April 1991;20:418-420.]

I N T R O D U C T I O N A case is presented to both demonstrate the apparent ease with which

the spines from the sand brier can penetrate and even perforate the cornea and emphasize the importance of magnification in examination of ocular trauma patients.

CASE REPORT A 27-year-old man was rabbit hunting without any eyewear and "walked

into a bush that scratched [his] right eye." Because the eye became pro- gressively more photophobic, red, and swollen, the patient presented to an emergency department two days later, where he was examined by a physi- cian. He was told "it was nothing more than a scratch," and given erythromycin ophthalmic ointment to apply four times a day. The patient as well as the ED record indicated that no magnifying optical device was used for examination. Because the eye was still "irritated," the patient saw his optometrist the following day, who identified several deeply embedded corneal foreign bodies and referred the patient for ophthalmological care.

The patient's eye examination was remarkable for best corrected acuity of 20/20 OD and 20/20 + 2 0 S . The external examination was remarkable for the absence of any enlarged preauricular or submandibular lymph nodes, 1 + lid margin edema and hyperemia, 2 + diffuse conjunctival hyperemia, and the absence of any extracorneal foreign bodies. The eyelids were double everted. The left eye was white and quiet. The pupils and motility were unremarkable.

The slit-lamp examination was remarkable for the right cornea, which revealed five linear, somewhat translucent, yellow-brown foreign bodies, each of which measured approximately 0.3 x 0.8 x 0.1 mm and was sur- rounded by a localized zone of 1 + active edema infiltrate (Figure 1). The approximate location of the nasal-most foreign body was the 3 o'clock position, 3 mm from the optical center, and it had penetrated to one half the stromal depth. The second was located midway between the 4 and 5 o'clock positions, 5 mm from the optical center, and it had penetrated to one fourth the stromal depth. The third was located at approximately the 5 o'clock position, 5 mm from the optical center, and it had penetrated to one half the stromal depth.

The fourth foreign body was located midway between the 5 and 6 o'clock positions, 3 mm from the optical center, and it penetrated to one fourth the stromal depth. The fifth was located midway between the 7 and 8 o'clock positions, 3.5 mm from the optical center, and it had just barely penetrated through Descemet's membrane.

These foreign bodies had no significant external extensions that could be easily grasped and removed during the slit-lamp microscope. In addition, at approximately the 6 o'clock position, 4 mm from the optical center, there was a 0.2-mm, 1 + active infiltrate that did not contain any foreign matter.

Kevin B Miller, MD Wisconsin Rapids, Wisconsin

From the Central Wisconsin Eye Clinic, Wisconsin Rapids; and the Department of Ophthalmology, University of Wisconsin, Madison.

Received for publication September 24, 1990. Accepted for publication October 30, 1990.

Address for reprints: Kevin B Miller, MD, Central Wisconsin Eye Clinic, PO Box 309, 400 Dewey Street, Wisconsin Rapids, Wisconsin 54495-0309.

126/418 Annals of Emergency Medicine 20:4 April 1991

SAND BRIER Miller

3 "i"i 5

FIGURE 1. Sl i t - lamp photograph with 25X magnification.

FIGURE 2. Horse nettle, Sand brier (Solanum carol inense) . 1, top of plant; 2, lower portion of plant; 3, stem with mature berries; 4, mature and immature berries; 5, flower; 6, top and edge view of seeds; 7, distri- bution. Perennial, reproducing by seeds f rom creeping roots tocks . Stems simple or branched, hairy and prickYy, 1 to 4 feet tall. Leaves alter- nate, oblong, wavy-edged or lobed, wi th yel low prickles on petioles, midrib, and veins. Flowers white or bluish, f ive- lobed, abou t i inch across, borne in clusters. Berries yellow, juicy, 3/8 to s/8 inch in diameter, containing numerous seeds, borne in clusters, smooth at first but becom- ing wr ink l ed late in the season. Seeds about 1/16 inch in diameter, round, flattened, yellowish. Found in fields, gardens, and waste areas, es- pecially those with sandy soil.

Reprinted by permission: Weeds of the North Central States, BuIietin

772, University of Illinois at Urbana- Champaign College of Agriculture, Agricul tural Exper iment Station, 1981, p 160.

The Seidel test with 10% fluorescein was negative. The anterior chamber was deep and quiet. The remainder of the eye examination, including a di- lated fundus examination, was unremarkable.

The patient was taken to the oper- ating room on an emergency basis. Retrobulbar anesthesia was adminis- tered. Miosis was induced by pilocar- pine hydrochloride 1% to minimize possible phototoxicity from the oper- ating room microscope. A culture of the conjunctival cul-de-sac was ob- tained; this was subsequently read as "sparse growth diptheroids." An at- tempt was made to grasp each of the five foreign bodies with a jeweler's forceps, following the lines of entry into the cornea. This was not suc- cessful for any of the foreign bodies.

An approximate 0.3-ram kerato- tomy was made with a 15-degree sur-

gical blade along the axis of entry of each of the foreign bodies. The foreign bodies were then easily grasped and removed with a jeweler's forceps. In no instance did the incision need to be more than two thirds of the depth of the corneal stroma. The foreign bodies were submitted for aero- bic, anaerobic, fungal, and mycobac- terial cultures; these all were negative. A repeat Seidel test with 10% fluorescein was negative.

Postoperatively, the patient was placed on a tapering schedule of to- bramycin ophthalmic ointment. He was followed up at days I and 2, one week, three weeks, and two months, with an unremarkable course. Specif- ically, he demonstrated prompt reso- lution of all of his symptoms, prompt replacement of the focal zones of edema and inf i l t rat ion wi th focal zones of trace stromal scarring, and final uncorrected vision of 20/15-1 OU.

D I S C U S S I O N With the assistance of the patient

20:4 April 1991 Annals of Emergency Medicine 419/127

SAND BRIER Miller

and the county extension agent, we were able to identify the "bush" as a sand brier, also known as horse nettle (Solanum carolinense) (Figure 2). It was interesting to note the apparent ease with which the spines, or prickles, penetrated and perforated the patient 's cornea as a result of relatively minor trauma.

An in formal t e l ephone survey taken of EDs in Wisconsin found that

the majority had magnifying devices and, in particular, slit-lamp micro- scopes. It was also found that the majority of emergency physicians rou- tinely used these devices in the care of eye trauma.

S U M M A R Y The use of some instrument for

microscopic examination of the traumatized eye is axiomatic to ophthal-

mologists, optometrists, and the majority of emergency physicians. Mi- c roscop ic , p r e fe rab ly s l i t - lamp biomicroscopic, examination of the traumatized eye should become rou- tine in all emergency care of the eye.

REFERENCE 1. Paton D, Goldberg MF: Management of Ocular Injw ries. Philadelphia, WB Saunders, 1976, p 1-14.

ERRATUM

Table 1 of the article "Early Detection of Acute Myocardial Infarction in Patients Presenting With Chest Pain and Nondiaguostic ECGs: Serial CK-MB Sampling in the Emergency Department" [December 1990;19:1359-1366], con- tained several pieces of incorrect information. The corrected table appears below.

TABLE 1. Summary of four immunochemical methods and one electrophoresis method for serum CK-MB determination*

Zero Hours

Method Immunochemical Coming Magic~-Lite Baxter Stratus ~ Hybritech Tandem~-E Hybritech ICON-QSR® Electrophoresis Helena REP~

Patient Positive Predictive Negative Predictive No. Sensit ivity Specificity Value Value

183 54.8 (Cl 49.9-59.7) 96.7 77.3 91.3 176 62.1 (Cl 57.2-67.0) 84.2 41.9 91.7 173 50.0 (CI 45.1-54.9) 97.2 79.0 90.3 142 50.0 (CI 45.1-54.9) 96.6 75.0 90.5

167 34.5 98.6 83.3 87.7

Three Hours

Method Immunochemical Coming Magic~-Lite Baxter Stratus ® Hybritech Tandem@-E Hybritech ICON-QSR~

Electrophoresis Helena REP ~

Patient Positive Predictive Negative Predictive No. Sensit ivity Specificity Value Value

171 96.7 (CI 94.8-98.6) 94.3 78.4 99.2 175 96.4 (Cl 94.5-98.3) 83.0 51.9 99.2 164 96.2 (Cl 94.3-98.1) 94.2 75.8 99.2 135 92.0 (Cl 90.1-93.9) 96.4 85.5 98.2

164 76.9 98.6 90.9 95.8 *The above values are all in percentages using standard calculations for sensitivity, specificity, positive predictive value, and negative predidive value. Confidence intervals are calculated al 95% for the immunochernicel assay sensilivities.

128/420 Annals of Emergency Medicine 20:4 April 1991

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Attack of the sand brier